HypnoBirthing Program Enrolment

Pregnant Person's First Name:

First Name

Pregnant Person's Last Name:

Last Name

Date of Birth

This is your date of birth not your baby's estimated due date.

Please fill in your preferred pronouns:

Please fill in your preferred identifying term within the birthing journey:

Mailing Address

This is needed for mailing you your HypnoBirthing package which contains your workbook textbook and other goodies. If you are a local Whitehorse resident, we can arrange a drop-off instead. Contact me to set this up.

Email contact

example@example.com

Phone contact

Format: (000) 000-0000.

Alternate phone

Format: (000) 000-0000.

Can I text you via WhatsApp on this phone?

Other

What is your preferred contact method? (By default, I communicate by email throughout the course but please let me know if you prefer me to use additional means to contact you.)

Birth Companion's first name

(birth companion is the person who will be your primary support in the birth room)

Birth Companion's Email

example@example.com

Birth Companion's relationship to you:

Please fill in your preferred identifying term within the birthing journey:

Do you have a birth assistant? This would be an extra person in addition to your primary birth companion who will attend the birth.

Birth Assistant's name and relationship to you:

First Name, Last Name; Doula / Friend / Other

Care Provider's name and title:

(i.e. First name, Last Name; GP Doctor / Midwife / Obstetrician) * If unknown or your clinic operates as a team, then just state "Unknown or Team"

Care Provider's clinic and location:

Clinic; City, Province or Territory

Birth Facility name and location where you plan to give birth:

Facility Name; City, Province or Territory. If this is a home birth, just state "Home"

Have you birthed before? What baby number is this?

Yes / No; Baby #

When is baby expected?

Do you have any health or obstetric concerns?

Do you have any significant mental or physical health concerns?

This would include anything related to a mood disorder, substance use, complex PTSD, severe anxiety or depression, epilepsy, cancer, or other serious health condition.

What are some of your hopes for this upcoming birth?

Include any values, goals or preferences

Course Location

Course Format

Course Date - I wish to enrol in the 5 Week HypnoBirthing Course Series starting:

Please specify the start date as (mm-dd-yyyy)

How many weeks pregnant will you be when you begin classes?

How did you hear about me?

Anything else you'd like to share?

Please feel free to share anything else you feel is relevant for your birth preparation journey! I am happy to hear more about how I can best support you.

Consent for Contact by HypnoBirthing International:

Risk and Liability Disclaimer

I hereby state that I am enrolling in the HypnoBirthing program of my own free will and with the understanding that this is a program designed to teach me to use my natural abilities to bring my mind and my body into a state of relaxation. I further understand that the content of these sessions is in no way intended to be represented as medical advice nor as a prescription for medical procedure. I am aware that I should seek the advice of a health-care provider to answer any health-related or pregnancy- related issues surrounding my pregnancy, my labour, or my birth.

I agree to take responsibility for using any information provided to me entirely at my own risk. This includes any physical exercises, comfort techniques, labour and birthing positions, or nutritional information. I assume all risks associated with participation in this program, including but not limited to any risk of injury from participating in any exercise.

I therefore agree that I will in no way hold the instructor of the HypnoBirthing program, or the HypnoBirthing Institute (its owner, or its representatives) responsible for any special circumstances that could arise as a result of my pregnancy, my labour, or the birth of my child; and I agree that neither I nor any member of my family will make any claim or initiate any suit against any of the above-named parties now or at any time in the future.

The Embodied Birth Website and HypnoBirthing Program may contain references or links to materials from third-parties. Reference to any third-party products, services, processes or other information, by trade name, trademark, manufacturer, supplier or otherwise does not constitute or imply endorsement, sponsorship or recommendation thereof, or any affiliation with us. We are not responsible for examining or evaluating the content or accuracy and we do not warrant and will not have any liability or responsibility for any third-party materials or websites, or for any other materials, products, or services of third parties. We are not liable for any harm or damages related to the purchase or use of goods, services, resources, content, or any other transactions made in connection with any third-party websites. Complaints, claims, concerns, or questions regarding third-party products should be directed to the third-party.

Pregnant Person's Signature

Date Signed

Date

PROGRAM ENROLMENT FORM

GENERAL INFORMATION

SUPPORT INFORMATION

PREGNANCY & BIRTHING INFORMATION

OTHER INFORMATION

ENROLMENT AGREEMENT