Online Enrolment Form
Your Name
Partner's Name
Post Code
Contact Numbers
Mobile (Yours)
Mobile (Partners)
Email Address (Home)
Your Occupation
Partner's Occupation
Health Fund
General Health
Do either of you have any irrational fears or phobias (Eg: Water, Heights)
Are you currently being treated for any physical or psychological issues
Is this the birth of your
Due Date / Hospital (name if applicable)
Are you having a Hospital or Homebirth?
Name of Doctor / Midwife
Which Class Dates / Location are you booking?
What Class are you Interested in?
How did you hear about this class?
What are your feelings about the birth prior to commencement of this class?
What kind of birth would you like to achieve?
Is there any specific fear you have regarding the birth or becoming a parent?
If you have any special place in nature where is it? (Eg: Beach, Mountains)
Hobbies or Interests:
Disclaimer: The Classes Programs include psychological & emotional preparation for birth. I understand that the delivery of the course will include guided relaxation as a means to facilitate emotional subconscious healing of fear and anxiety about childbirth.
Yes, I understand
If you are under the care of a psychologist or psychiatrist please provide a letter of approval for you to attend the course of interest.
Yes, I understand