Mama Cabinet Childbirth Education & Resources: Private Coaching Intake Form
Hello and Welcome!

Thank you so much for contacting me! It truly is an honor for me to work and assist you in your most exciting and impactful journey!

The form below is a basic set of questions to help you and I get to know each other a little better and for me to help provide my services in the best possible capacity for you and your birth team.  

Please note, that I am not a healthcare professional or a doula (yet), my participation in your journey is to provide informed childbirth education that may help you make an informed decision for birth.  Anything that will be shared in our sessions is based on my own research and findings from public evidence-based material and is subjected to changed based on the most updated research and data.  If you have questions about what is shared in our sessions, please feel free to contact me at any time and/or your care provider for further details.

Please fill out the form below and click submit. After the form has been submitted, please allow maximum 72 hours for me to review your answers and to contact you for further booking.  Once your form has been reviewed and you have received a confirmation of booking, a payment based on your choice of payment plan and method below will be required to submitted within 48 hours of approval for services to begin.

A few things to take note of as you are filling out the form:

1. Please do not submit any form of payment until this form has been reviewed and a confirmation of booking has been approved.
2. All deposits will NEED to be due for guarantee of booking.  The remaining amount will need to be paid in full by our first session together.  Other arrangements are available and will be determined by a case-by-case bases. 
Please notify me if you wish to make other arrangements.  Services will not start or continue if these terms are not followed or until other payment plan options are discussed and have been approved.  
3. ALL SALES ARE FINAL.
4. If you need to reschedule any of our sessions, please do so at a minimum of 24hrs before our session.
5. Any/no response will be considered void, and services will be stopped and a refund for services that have been used or not will not issued. 
6. If a birth partner has been named on the submitted form, please include their contact information and their participation will be expected in some or all our sessions.  If other arrangements need to be made in regard to this, please contact me.

If you have any further questions or concerns, please feel free to contact me through phone or email. I am available on Monday-Sunday from 8am - 9pm. Any assistance after these hours will be attended to on a case-by-case bases or will be answered the following morning.  


Email: 
Info.amandamejia13@gmail.com

That's it! Let's get down and birthy! 

Cheers!
Email *
What is your first and last Name? *
What is your birth partner first and last name and contact info? (If no partner, answer N/A) *
What is the best way to reach you? Please include contact number and email. *
What is your estimated due date? *
MM
/
DD
/
YYYY
How far along are you currently? *
Is this your first pregnancy? *
If you answer no above, have you had a C-Section? *
If you have had a C-section, are you wanting to do a VBAC? (Vaginal birth after cesarean)
Clear selection
Any diagnoses during this pregnancy I should know about? (Gestational Diabetes, Preeclampsia, etc.) *
Where are you currently located? (City, State) *
Do you know where you are going to give birth? *
If you answered yes above, what is your birth place choice? *
Will you be using any doula services for your upcoming birth? If so, who? *
If you are not using a Doula for your upcoming birth, would you like to receive some recommendations? *
You are registering for a full comprehensive private Childbirth Education classes, how will you be making this payment? *
Coupon Code:
Will you be needing a payment plan?  *
Please choose payment method *
Please explain in a few words what you are looking to learn from our session together? *
To better provide my services, are there any specific things you would like me to focus on that are important to you? *
As part of my services, I provide educational materials for some of the topics that will be covered in our time together through a shared google doc, are you okay with this? *
I am currently available Mondays and Thursdays from 6:30- 9:00 p.m., Friday 6:30-8:00 p.m., and Saturdays 10:00 a.m. - 12:00 p.m. Do any of these days and times work for you? *
Required
Classes should not start no later than 28 weeks, how soon are you wanting to begin your classes? *
MM
/
DD
/
YYYY
In reference to previous question, are there any specific nights/days and times that do NOT work for you and your birth partner? *
3 out of the 6 sessions are virtual via zoom, are you okay with that? *
The last two sessions are the hands--on portion of the class and can be as long as two (2.5) hours each.  I prefer to do these classes in the comfort of your own home, are you okay with that? *
Once your classes have ended, are you willing to submit a review for our time together? *
A copy of your responses will be emailed to .
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms