HYPNOBIRTHING INTAKE FORM Name * First Name Last Name Preferred Email * Permanent Email (after baby is born) Postal Address Address 1 Address 2 City State/Province Zip/Postal Code Country Birthing Companion(s) Example name of partner, spouse, family member or doula. Care Provider Name & Title Example midwife, doctor, obstetrician. Hospital/Birthing Facility Please provide name of place and location. Is this your 1st, 2nd, 3rd etc. baby? How many weeks pregnant will you be when you begin classes? Is this birth a VBAC or is there any important information/medical conditions/psychological or psychiatric treatment you need me to be aware of before classes commence? Enrolment Deposit To hold your place in the class, I kindly request a $150 non-refundable tuition deposit. Final payment is due 7 days prior to course start date. Yes I agree to this. No thank you, I don't wish to proceed. Thank you for your enrolment. I simply cannot wait to teach you how you can use the power of yoga to birth calmly without feeling overwhelmed by the pain of labour!
