Participant Type
*
Pregnant Person
Professional
Partner
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Age
Your Occupation / Profession
*
Which MIL Online Class Series are you attending?
*
Please Select
MIL Series 2021-A (Mar)
MIL Series 2021-B (May)
MIL Series 2021-C (Jun/Jul)
MIL Series 2021-A (Sep)
MIL Series 2021-A (Dec)
Due Date
-
Month
-
Day
Year
Date
Person(s) sharing pregnancy with you (if any), including name, age, phone, & occupation
Partner's Name
First Name
Last Name
Relationship Type & Duration
Was this a planned pregnancy?
Yes
No
Other
Any difficulties conceiving?
Yes
No
Please describe the difficulties you had conceiving.
Are you having or have you had any pregnancy-related medical concerns during this pregnancy (e.g., bleeding, preterm labor, hypertension, gestational diabetes)?
Yes
No
Please describe the pregnancy-related medical concerns during this pregnancy (e.g., bleeding, preterm labor, hypertension, gestational diabetes).
Have you ever been present at a birth (other than your own)?
Yes
No
Please provide details of other births you have been present at.
Did you have any health issues before you became pregnant?
Yes
No
Please describe the health issues before you became pregnant?
Do you currently have any health problems?
Yes
No
Please describe your current health problems?
During your pregnancy, have you experienced or are you currently experiencing anything particularly stressful (e.g., moving, remodeling your home, a job change, relationship difficulties, family illness)?
Yes
No
Please describe your stressful experiences during pregnancy (e.g., moving, remodeling your home, a job change, relationship difficulties, family illness)? If yes, please describe.
Are you currently taking any medication(s)?
Yes
No
Please detail the medication(s) you are taking.
Have you ever been hospitalized or had any surgery?
Yes
No
Please describe any hospitalizations or had any surgery.
Are you currently seeing a psychotherapist?
Yes
No
Please describe the nature and frequency of visits to a psychotherapist.
Have you had any previous experience with meditation or yoga?
Yes
No
Please describe your previous experience with meditation or yoga.
Do you currently do any form of exercise?
Yes
No
Please describe your current form of exercise.
Have you given birth to a baby before this pregnancy?
Yes
No
Please provide details for each baby.
Baby 1
Baby 2
Baby 3
Baby 4
Name
Birth Date
No of weeks pregnant before delivery
Hours of labor
Type of delivery
Place of delivery
Baby weight
Have you had any miscarriages?
Yes
No
Please provide dates of miscarriages
Have you had any difficulties during any of your previous pregnancies, childbirths, or postpartum experiences (including breastfeeding)?
Yes
No
Please describe the difficulties you have had during any of your previous pregnancies, childbirths, or postpartum experiences (including breastfeeding).
What are your intentions regarding breastfeeding?
Have you made any plans for help after the baby is born?
Yes
No
Please describe the plans for help after the baby is born?
If you are currently working or in school, what are your plans after the baby is born?
*
What gives you the most pleasure in your life right now?
What is most stressful in your life right now and how do you usually cope with it?
Please describe any specific hopes or fears regarding your pregnancy, childbirth, or parenting you may have.
Do you have any particular hopes or fears regarding your partner's pregnancy, childbirth, or for the two of you caring for a newborn?
How did you hear about the Mind in Labor Workshop?
Mindful Birthing Website
Referral from doula
Referral from Midwife
Friend referral
Facebook
Instagram
Google
Internet search
Other
What are you hoping to learn from this course?
Care provider's name & phone
Intended Birthplace
*Local* Emergency Contact name & phone (not your partner)
Is English your primary Language?
Yes
No
Other
Have you completed an MBSR or MBCT course?
Yes
No
Have you attended any mindfulness-based professional training programs?
Yes
No
Please provide details of the mindfulness-based professional training programs you have attended
Do you have a regular meditation practice?
Yes
No
Please provide details of your regular meditation practice?
Do you have a regular movement practice?
Yes
No
Please provide details of your regular movement practice?
Have you attended a 5-7 day silent retreat?
Yes
No
Do you have perinatal health experience?
Yes
No
Please provide details of your perinatal health experience
Have you attended any other MBCP events or presentations?
Yes
No
Please provide details of the MBCP events or presentations you have attended
Why are you interested in attending the Mind in Labor online class?
Please provide a *Local* Emergency Contact name & phone
Healthcare Professionals Declaration
I understand that healthcare professionals are invited to attend our MBCP Online course alongside expectant parents as participant-observers. Completing the MBCP Online course does *not* qualify me to teach MBCP or lead mindfulness practices. If I wish to learn more about MBCP Teacher Training, I will visit the website www.mindfulbirthing.org/teach.
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