Private Course Registration Form - shebirths.com

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PARTICIPANT DETAILS

Use the form below to complete your registration details . If you run out of time you can save the form and return to it any time with in 30 days. Please note that the completion of this form does not guarantee you a place in your preferred course, payment must be received prior to your place being confirmed.

To be completed by both attendees if possible
All information is strictly confidential

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Personal Information
Mum's Details
Mum's Name*
Date of Birth*
Occupation*
Partners's / Class Companion's Details
Partner's / Class Companion's Name*
Date of Birth*
Occupation*
Other Personal Details
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Personal Email*
Mobile Number*

General Information
How did you hear about She Births®?
- Yoga
- Google
- Natural Therapist
- Friend
Referal Name

Provide their name if possible
Please describe your feelings about this approaching birth and parenthood*
What do you hope to gain from the She Births® course?*
Have you done any other childbirth preparation classes?*
Please describe your favourite place in nature*
What do you enjoy doing?*

Pregnancy Details
Estimated Due Date*
Gestation at time of course*
Birth location*
delivery suite / birth centre / home
Caregiver's details and name
team midwifery / GP shared care / obstetrician / public / private / independent midwife
Doula's name
if applicable
Are your caregivers supportive of the She Births® classes?*

Health & History
Please detail any cervical procedures or operations you have had*
Do you have any previous or current pregnancy health issues?*
Do you have any other children or have you had any other pregnancies?*
Please describe your feelings about previous birth experiences you have had or have witnessed*
Do either of you have any of the following?
- Irrational fears or phobias e.g. Water, lifts
- Psychological conditions e.g. Depression
- Take medication on a regular basis
- Use drugs recreationally
MUM
On a scale of 0 - 6 how high would you rate your anxiety about birth?*
- 0
- 1
- 2
- 3
- 4
- 5
- 6
On a scale of 0 - 6 how high would you rate your anxiety about early parenthood?*
- 0
- 1
- 2
- 3
- 4
- 5
- 6
PARTNER
On a scale of 0 - 6 how high would you rate your anxiety about birth?*
- 0
- 1
- 2
- 3
- 4
- 5
- 6
On a scale of 0 - 6 how high would you rate your anxiety about early parenthood?*
- 0
- 1
- 2
- 3
- 4
- 5
- 6
Are you agreeable to this information being used for research with all names remaining confidential?*
- Yes
- No

Preferred Course Dates
Private courses are taught over 2 x 3.5hrs. Held on Tuesdays, Wednesday or Thursday every fortnight. Times are 12-3.30pm or 4-7.30pm. Please let us know what you prefer and we will try to accommodate.
First Preferred Course Date
Second Preferred Course Date
Preferred Educator (If Available)
If your preferred educator is not available then we will help you find the best She Births to suit your needs
Comments
This field is for validation purposes and should be left unchanged.

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