Registration | Sue Power — Counsellor & Psychotherapist, Birth Educator

Course Enrolment Form

Workshop Registration

Name *

Occupation/s

Spouse/partner/birth support name

Occupation/s

Best contact number *

Next best contact number

Best contact email *

Please include an email address that will be current for an online evaluation to be sent to you approx two months following the birth. Thank you.

Contact person in case of emergency *

Emergency contact persons phone number *

Any medical conditions or pregnancy complications?

Mental health diagnosis (past or current?) and current medications

Is this the birth of your... (pick from list)

Birthing month? *

Any previous or current pregnancy complications? *

Is this an assisted conception/IVF ? (optional)

Private Health Insurance Provider (if applicable for rebate)

Care Provider for Birth

Place of birth birth

i.e. home, hospital, etc

What are your current feelings and/or expectations about your birth experience?

Are there any specific fears/concerns you have regarding the birth or becoming a parent?

Anything else of significance that you would like to discuss or feel is important for the practitioner to know?

If you are human, leave this field blank.