Full Name
Email
*
Phone
*
Voxer Username (if you have one)
Pregnancy Status
Currently pregnant
Planning to become pregnant soon
Not sure, exploring options
Experienced a recent pregnancy or infant loss
How many times have you been pregnant before?
How many babies have you had?
When is your due date? (If not pregnant, just list today's date)
Do you currently have a midwife or OB/GYN provider?
Yes, I have an Ob/GYN
Yes, I have a midwife
Yes, I have both
No, I do not have a provider yet
Have you experienced any pregnancy complications, such as preterm labor, miscarriage, or infant loss? If yes, I'm sorry for your loss. Please explain what you are comfortable sharing.
Did you feel supported and respected by your healthcare providers during those experiences?
Yes, I felt supported
No, I had challenges
It was a mixed experience
Not applicable
Is there anything specific you'd like us to focus on regarding your past experiences with healthcare providers?
Are there any concerns about your current pregnancy that you'd like us to address through the program?
What do you hope to gain from the Midwife Mentor program?
How did you hear about Midwife Mentor?
Friend or family referral
Social media
Website
Healthcare provider
Online search
Other
Have you ever attended childbirth classes?
Are you interested in any specific topics or areas of focus within the Midwife Mentor program?
Is there anything else I should know before we chat?
I agree to
terms & conditions
provided by the company. By providing my phone number, I agree to receive text messages from the business.
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