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Empowered Birth Retreat Application
The first 6 women to get their paperwork and deposit in will secure a spot at the first Empowered Birth Retreat! Fill out the answered in this application and we will let you know if you are one of the 6 attending this powerful and life changing event!
To learn more go to:
https://birth-bliss-beyond.ck.page/c21597f11a
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* Indicates required question
Email
*
Your email
Name
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Your answer
Have you given birth before? Briefly explain your experience.
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Your answer
What are 3 words that describe your mothers attitude towards birth?
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Your answer
How would you rate your fear of birth from 0-10
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No Fear
0
1
2
3
4
5
6
7
8
9
10
Worst Fear Possible
What is your goal for the birth retreat?
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Your answer
How far along are you?
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Option 1
Are you ok with sharing a bed with another attendee?
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Yes
No
How comfortable are you with your care provider?
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Not comfortable
0
1
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3
4
5
6
7
8
9
10
Very comfortable
What is your support system like?
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Your answer
How educated are you on the birth process?
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Not Educated
0
1
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3
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5
6
7
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9
10
Very Educated
Do you have any aversions to food/scent?
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Your answer
Do you promise to read Gentle Mothering, Gentle birth by Sarah Buckley before the retreat?
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Yes
No
Is there anything else we should know about you?
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Your answer
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