Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What services are you interested in? *

Hospital Birth

Home Birth

Free Birth

Birth Debrief

Postpartum Doula

Therapeutic 1:1 Sessions

Conception

Other

Are you pregnant? If so, do you know your 40 week date?

("due date")

MM

DD

YYYY

I understand that Emily is not a licensed Midwife, Certified Doula, LC, nor a L&D Nurse and will not be operating within that scope of practice (fetal heart tones, baby positioning, coached pushing, medication administration, et al) and I will be required to sign release of liability forms. *

yes

no

I am ready and willing to take full responsibility for me, my baby and our birth experience. *

ye

no