Online Registration

The following form is to register for your preferred series.

If you prefer old-fashioned paper (i.e. not online),

let me know and I can email a document.

If you have questions about these questions,

please read the Privacy Policy first (see below);

you can contact me at 416 255 8333.

ChildbirthJoy Prenatal Hypnosis Registration

Please note that all fields followed by an asterisk must be filled in.

Your name (pregnant client)*

Your partner’s name*

Which ChildbirthJoy series are you registering for?*

Mailing address with city & postal code*

best phone to contact

email (pregnant client)*

email (partner)

You prefer your partner to be identified as (for those in a relationship)

	partner
	husband
	wife
	other (please specify)

Other

First Baby?*

	Yes
	No

Summary of previous pregnancies/births

Due Date (DD/MM/YY)*

Careprovider*

	Registered Midwife
	Family Practice Physician
	Obstetrician
	Traditional Birth Attendant
	Other

Careprovider’s name*

Your careprovider is aware you are using hypnosis*

	Yes
	No
	Not Discussed

I allow Shawn to mail a form letter to my RM/MD*

	Yes
	No
	Other

Planned place of birth*

	Home
	Hospital
	Toronto Birth Centre
	Other

If hospital, please indicate name

Doula?

	Yes
	No
	Not decided yet

If hiring a doula, specify name

Additional prenatal classes planned this pregnancy?

	Yes
	No
	Have not decided yet

Additional prenatal classes or other?

Pregnant client’s birthdate (DD/MM/YY)*

Your occupation

Your educational level/degrees/diplomas

Partner’s birthdate (DD/MM/YY)*

Partner’s occupation

Partner’s educational level/degrees/diplomas

For either of you*

	epilepsy
	mental illness requiring psychiatric care
	other
	none

If yes to any of the above, please indicate or contact me

Do either of you have Raynaud’s Syndrome?*

	Yes
	No
	Do not know

Pharmaceutical medication use in pregnancy?

	No
	Diclectin (or other anti-nausea)
	Thyroid Rx (or other)
	Other

If other, please indicate

Previous experience with (check all that apply)*

	Hypnosis
	Meditation
	Yoga
	None
	Other

What would you like addressed during this course?*

Group emails can facilitate interaction. Do you agree to be included?

	Yes
	No
	Not sure

The monthly newsletter has free offers and more...

	Yes, sign me up!
	No thanks
	Maybe later

How did you hear about this course?*

Payment preference:

	email transfer $448.61
	$465.56 PayPal (this includes a service charge of $15)
	$412.00 Paypal for those who don't live in Canada
	Other (please indicate)

I allow Shawn to share online recording with my class members*

	Yes
	Other

If other, please specify

I agree to not share recordings with anyone other than class members*

Yes

I have read and agree to the Privacy Policy (below)*

	Yes
	Other

If other, please note

Please enter the word that you see below.

By completing the Intake Form, you agree to the following Terms and Conditions and Privacy Policy:

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Thank you!