Birth Plan Survey
This form is intended to uncover thoughts, fears, and mental blocks you have as you prepare for your VBAC. It is also intended to highlight areas of education you could improve on. This form is not intended to diagnose or treat any conditions and feedback on this form does not constitute medical advice. Any feedback on this form is purely informational and inspirational. Submitting this form and receiving FREE feedback does not initiate a business contract or formal relationship between the surveyor and surveyee. By responding to and submitting this survey, you agree to the above mentioned conditions.

Submit this survey within 72 hours of the Birth Plan Workshop for free personalized feedback and tips for a positive birth experience

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Email *
First Name *
Last Name *
Email Address *
State/Country *
How many previous births have you had? How many were cesareans? How many were vaginal? What was the reason for your previous cesarean(s)? *
Share your number 1 reason VBAC is your goal *
What are THREE GOALS you have for this birth? How do you plan to achieve them? *
Who is on your birth team? *
On a scale of 1-5, how confident are you in your provider's supportiveness of your birth goals? *
Not Very Confident
Very Confident
On a scale of 1-5, how confident are you in your ability to advocate for yourself effectively? *
Not Very Confident
Very Confident
On a scale of 1-5, how confident are you in your likelihood to make decisions out of intuition & information? *
Not Very Confident
Very Confident
On a scale of 1-5, how likely are you to make decisions based out of fear? *
Very Likely
Not Very Likely
On a scale of 1-5, how easy is it for you to surrender? *
Not very Easy
Very Easy
Who is the most supportive person in your life cheering you on for VBAC? *
Do you feel your birth partner is confident in their ability to support your VBAC goals? *
What are your top three fears about VBAC? *
What questions about VBAC do you feel like you're struggling to get answers to? *
What part of the Combating Fear During your VBAC Workshop resonated the most with you or did you find the most helpful? *
Have you written your birth plan? *
Do you need help writing your birth plan? *
Do you need help writing your birth plan? *
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