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Your Empowered Birth Intake Form
Answer these quick questions to help us find the fastest path for you to get your dream birth. Please be aware that if you are applying for entry to one of our Empowered Birth Academy coaching programs or to work with Carly for individual coaching sessions that filling out this form is a REQUIREMENT in order to be considered as an applicant.
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Name
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Your answer
Email
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Your answer
How did you hear about EmpoweringMomsBirth.com?
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Your answer
Is this your first baby?
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Yes
No
I'm not pregnant yet but looking at my options
If you're already pregnant, how far along are you? If you're NOT pregnant yet, what is your timeline for when you intend to conceive by?
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Your answer
Have you read "Your Empowered Birth" yet?
(Please note that to qualify for a complimentary coaching session or enrolment into one of our higher level group programs, this is required reading so that you come in with a solid foundation)
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Yes, cover to cover and I have done all the journal exercises
Yes, I have read it but haven't done the exercises yet
Not yet, but I have a copy and will read it before booking my complimentary session should I qualify for it
Have you gone through the Birth Vision Mini Course at EmpoweringMomsBirth.com/birthplan yet?
(Please be aware that to qualify for a complimentary coaching session, having your birth vision completed or partially completed to the best of your ability is a requirement as we will go over this plan in order to optimize it and find any pitfalls and correct them)
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Yes, and I have my completed birth vision including my list of fears and preferences for my birth
Not yet, but I will go through it before booking my complimentary session should I qualify for it
If you could have your birth any way you wanted, and you could NOT fail, what is your dream birth experience?
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Your answer
What are you most afraid of when it comes to attempting to achieve this dream birth?
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Your answer
On a scale of 1-10, how motivated are you to have this beautiful birth experience?
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Not that motivated; birth is gonna go how it's gonna go
1
2
3
4
5
6
7
8
9
10
Extremely motivated! I'll do anything to avoid a nightmare birth experience!
How much money are you able to comfortably invest in achieving this birth experience ?
(please note that 1-1 coaching is the most expensive option due to the customization and time commitment involved, however we do have lower tier programs and even free resources we can recommend if you are not a good fit for coaching)
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$0-$200
$200-$600
$600-$1k
$1k-$5k
I'll pay ANYTHING to get fast, customized, and optimized results for my birth experience, confidence in advocating for myself, and ability to achieve my dream birth and avoid my nightmare!
If you are chosen to qualify for a complimentary Empowered Birth coaching call do you promise to show up on time and take it as seriously as if you had paid for it?
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Yes, I always show up for my coaching sessions and other commitments
I will do my best, however if something comes up I promise I will notify you at least 24 hours in advance so that my time slot can be filled by someone else
My time is very limited right now; I think I might benefit more from a group program, course, or other resource that could get me similar results for less of a time commitment
Is there anything else you would like me and my team to know in order to help you better?
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Your answer
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