JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Comprehensive "Beyond the Birth" Workshop Enrollment Form
Please take a moment to answer these questions as will help us customize the workshop to meet your interests.
You can expect to receive an email from us within 24 - 48 hours of sending your response! In the meantime, please email us at info@4thTrimesterPlan.com with questions!
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Name
*
Your answer
Phone Number
Your answer
Email
Your answer
Facebook handle
Your answer
Due Date
MM
/
DD
/
YYYY
Where are you located in the valley?
Arcadia
Chandler
Gilbert
Phoenix
Scottsdale
Tempe
Other:
Clear selection
Which workshop series are you interested in attending? (Ideally, we recommend you complete the workshop by your 36th week of pregnancy.)
JAN 9, 16, 23 & 30, Thursdays, 6:30 to 8:30 pm - Arcadia Women's Wellness (4545 N 36th St #100, Phoenix, AZ 85018)
FEB 5, 12, 19 & 26, Wednesdays, 6:30 to 8:30 pm - Kids Rising (10842 N 32nd St, Phoenix, AZ 85028),
MAR 5, 12, 19 & 26, Thursdays, 6:30 to 8:30 pm -Arcadia Women's Wellness (4545 N 36th St #100, Phoenix, AZ 85018)
APR 1, 8, 15 & 22, Wednesdays, 6:30 to 8:30 pm - Kids Rising (10842 N 32nd St, Phoenix, AZ 85028)
MAY 7, 14, 21 & 28, Thursdays, 6:30 to 8:30 pm - Arcadia Women's Wellness (4545 N 36th St #100, Phoenix, AZ 85018)
Twins?
Yes
NO
Clear selection
How many children do you currently have?
None
1
2
3 or more
Clear selection
Other children names & ages:
Your answer
Preferred birth method:
C-section
Vaginal
Other:
Clear selection
Preferred birth location:
Hospital
Birth Center
Home
Other:
Clear selection
OB/GYN or midwife name:
Your answer
Preferred baby feeding method:
Breast
Formula
Undecided
Other:
Employment status:
Full-time employee
Part-time employee
Mom
Other:
If employed, expected time-off after baby:
Your answer
Projected employment status after baby:
Full-time employee
Part-time employee
Mom
Undecided
Other:
Partner's expected time off after baby
Your answer
Food allergies or aversions:
Your answer
Maternal / Paternal cultural heritage (e.g. as many known countries, regions, or ethnicities):
Your answer
What do you hope to gain from the workshop?
How to build a broader support network
Nourishing foods for my 4th Trimester
Therapies / treatments to aid my 4th Trimester recovery
How to balance life with my older kids & baby
Other:
Which best describes your approach to planning?
I love planning everything!
I plan some things.
I don't really consider myself a planner.
Other:
Clear selection
Check any of the following that describe your situation:
Financial stress
Marital stress
Pregnancy complications
Personal or family history of depression, anxiety or postpartum depression
Premenstrual dysphoric disorder (PMDD)
A major recent life event: loss, house move, job loss, etc
Having multiples
Received infertility treatment
Thyroid imbalance
Diabetes (type 1, 2 or gestational)
None of the above
How did you hear about the "Beyond the Birth" workshop?
Your answer
Is there anything else we should know? (a workshop session you'll have to miss, a question we should have asked, etc)
Your answer
Please select the payment option that works best for you. (We understand having a baby is expensive and never want $ to keep you from the 4th trimester experience you deserve. If needed, request the "CREATIVE FUNDING" option below). Investment: $299
ONLINE: I'll pay online via PayPal: elizabeth@4thTrimesterPlan.com
ONLINE: Please send me a PayPal invoice.
IN PERSON: I'll bring a cash or check to the first workshop session.
Please send me info about CREATIVE FUNDING options.
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
This form was created inside of Matrescence 4th Trimester Planning + Support.
Report Abuse
Forms
