Personal Information Pregnant Parent's Name * First Name Last Name Single Parent? Yes Pregnant Parent Identifies as: Female Male Non-Binary Other Partner's Name First Name Last Name Partner Identifies as: Male Female Non-Binary Other Phone * (###) ### #### Email * Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country What is your occupation? What is your partner's occupation (if applicable)? Pregnancy Information Estimated Due Date MM DD YYYY Name of Midwife/Doctor Planned Location of Birth Is this your first baby? Yes No If no, is there anything you'd like us to know about your previous birth experiences? Do you have any questions about nutrition or weight changes in this pregnancy? Do you have questions/concerns about breastfeeding/chestfeeding or bottle-feeding? What are any major sources of stress in your life? What helps you cope? Do you have any specific questions you'd like answered in these classes? How did you hear about us? Is there anything else you'd like us to know? Thank you The Childbearing Society Thank you!
