JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Rainier Valley Birth Center - Listening Session Pre-Survey
We would love to hear more about your vision for a community birth center that is created by the community for the community.
At the end of this short survey (2-7 minutes), we will invite you to join Rainier Valley Community Clinic in a 90-minute listening session where you share your vision with our planning team!
Sign in to Google
to save your progress.
Learn more
* Indicates required question
First Name
Your answer
Last Name
Your answer
Pronouns
*
Your answer
Email address
*
Your answer
Phone Number
Your answer
City
*
Your answer
State/Territory
*
Your answer
Zip/Postal Code
*
Your answer
Age
*
Under 12 years old
12 - 17 years old
18 - 24 years old
25 - 34 years old
35 - 44 years old
45 - 54 years old
55 - 64 years old
65 - 74 years old
75 years old or older
Gender Identity
*
woman
man
agender
androgynous
bigender
cis woman
cis man
genderfluid
genderqueer
gender nonconforming
hijra
intersex
non-binary
pangender
transfemme
transmasculine
transgender
trans man
trans woman
two-spirit
Prefere not to say
Other:
Required
Race/Ethnicity
*
Select all that apply.
Native American, American Indian, Alaska Native
Black
Afro-descendant
Latinx
Asian
Pacific Islander, Native Hawaiian
Indian
Middle Eastern
white
Other:
Required
Household Size
*
Please list the number of people living in your household/home
Your answer
Ages in Household
*
Please list the ages of the person(people) living in your household/home
Your answer
Are you answering this questionnaire as a ... ?
*
Client - previous, current, or future
Provider - healthcare or allied provider (e.g., midwife, nurse, doctor, doula, lactation consultant, student, etc.)
Community Stakeholder - representative of a community, association, organization, or group
Other:
Next
Page 1 of 5
Clear form
Never submit passwords through Google Forms.
This form was created inside of Yarrow.
Report Abuse
Forms
