My Birth Story
Whether you had a positive or negative experience you want to heal from, we want to hear from you.

Before you begin, please note that you can answer only the questions that you feel comfortable answering. Feel free to skip over any questions that don't apply to you.

We will use your stories to build community knowledge, inform future programs and/or classes and help us understand the community we are serving. We may potentially publish these without any identifying details to bring to light the issues that patients, families, and professionals face in reproductive healthcare today.
Sign in to Google to save your progress. Learn more
Please provide a name, nickname, fake name, or initials *
What is your email address? (this will not be shared or published)
Where did your experience occur? Select all that apply
What was the timeframe? Be as vague or specific as you like. (eg. Fall 2020 or January 2009 or Sept 16, 2014)
Tell us what happened.
What was the impact - either in the moment or longterm?
What is your advice for other birthing individuals?
Do you think your race or cultural identity impacted your care?
Do you have any feedback for healthcare professionals?
Would you be open to sharing your story on our online forum, without any identifying details?
Clear selection
Would you like someone to follow up with you?
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms