Mother's Info

Street Address:    Home Phone with area code:
City, State, Zip    Cell Phone with area code:
E-mail:

Partner's info, where different from Mother's

Street Address:    Home Phone with area code:
City, State, Zip    Cell Phone with area code:

These questions will help me adapt class material to students' needs, but are all optional.

How many weeks pregnant are you? weeks
Is this your first child? yes no
Are you presently receiving prenatal care? yes no
Have you chosen the health care provider who will assist you at the birth? yes no
The birth is being planned for home hospital birth center undecided

What is the Partner's relationship to Mother? Please note that order is alphabetical, not prioritized in any sense of value. Check as many as seem appropriate.
            doula
            father of child
            friend
            mother
            romantic partner
            sister
            other (please specify)

How did you hear about these classes?
             baby or birth expo
             doctor or midwife
            yoga teacher, naturopath, chiropractor or other health professional
            saw posted flyer
            print ad
            from former student
            is former student
            other word of mouth
            other (please specify)

Is there anything else about either of you that you'd like me to know?
Is there anything else about me that you'd like to know?
Mom, what do you hope to get out of these classes?
Partner, what do you hope to get out of these classes?
What are you enjoying so far about being pregnant?
What is more difficult for you about being pregnant?
Do either of you have any concerns or issues that we might need to address together before you attend class?

Your insurance company might reimburse you; I can help with this if you like.

See you soon!