This form needs to be postal mail or emailed with a deposit by check, PayPal or credit card to confirm your spot in the session at least 10 days prior to the beginning of the series you wish to partake in.

Copy and paste this into a word document to fill out,

or it can be sent to you via email for download. 

The program consists of live instruction with a Certified HypnoBirthing® Childbirth Educator. The program includes information-packed class sessions, helping you to understand why labor doesn’t have to hurt:
  • 5 professionally written scripts for your home practice
  • 4 recordings for your relaxation, stress reduction, and bonding (Including the program cornerstone, Rainbow Relaxation)
  • Documents for planning your Birth Preferences {hospital or home}
  • A set of Birth Prompts for your birth Companion {aka cheat sheet}
  • Demonstration and practice in optimal birth positions
  • A free hypnotic session in building birth confidence and eliminating fears
  • A Guide to good pregnancy nutrition
  • Several deep relaxation techniques for use during birthing
  •  Well-paced and enjoyable instruction designed for adult learning {by a Certified Meeting Professional} to build your confidence and help you to have a safer, easier, and more comfortable birthing
  • Special calm breathing methods for use throughout labor and during birthing
  • Small classes for personal attention
  • Body toning exercises and practice
  • The advantage and confidence of the Mongan Method reputation for top-quality birthing preparation
  • 3 videos to view at home at your leisure instead of taking time in class and…

NOT a part of the official HypnoBirthing® syllabus….

BONUS #1        “Happy Birthing Stories” via Facebook
BONUS #2       A CD of almost 100 educational documents
BONUS #3       “The Fourth Trimester” plan
BONUS #4        Yoga Birthing Method tips & techniques
BONUS #5        Birthing Story shared by couple that recently birthed
                …along with  support via phone/text/email before, during and after the program!

I look forward to joining you on your journey to welcome your baby!

 Enrollment Form -page 1-

Today’s date:_______

Mother: ____________________________________________________________Age:

Maiden Name: _______________________________________ EDD:____/ ___/____# weeks of pregnancy_______

Home Phone: __________________________ Cell Phone: ______________________________

Email: ________________________________________________________________________

Address: ___________________________________City/State/Zip: ________________________

Occupation: ____________________________________Work Phone: _____________________

Educational Level/Degrees: _______________________________________________________

Birth Companion’s Name: _____________________________________________Age: _______

Relationship to Mother: __________________________ Occupation: ______________________

Cell Phone: ______________________________Work Phone: __________________________

Email: ________________________________________________________________________

Baby/Babies Order of Birth: _____Gender(s): ______Nickname(s): _________________________

If not your first child, please list names and ages of siblings: ___________________________________________________

Obstetrician or Midwife Information:

Name: ____________________________________________Phone: ______________________

Address: _______________________________________City/State/Zip: ____________________

Email: ________________________________________________________________________

Birthing Location:

Name: ____________________________________________Phone: ______________________

Address: _______________________________________City/State/Zip: ____________________

Website: _______________________________________________________________________

Do you have any previous experience with hypnosis?  Y N

_______________________________________________________________________

Previous or current childbirth preparation classes? 

Type: _______________________________________Location: __________________________

How did you hear about HypnoBirthing®? _____________________________________________

What are your 3 most pressing concerns regarding your birthing experience?  

1_____________________________________________________________________________

2_____________________________________________________________________________

3____________________________________________________________________________

Enrollment Form – Page 2

Please state the dates and location that you are interested in:

________________________________________________________________________________

Thank you!

Once you have completed the above form, please scan/email forms and send deposit/full payment by PayPal or print out and postal mail {contact directly for address } with check or credit card information. The Client Bill of Rights and an Agreement Form will be sent via email as a pdf. Once we receive all completed forms and your deposit you will receive a WELCOME email with instructions and a link to an introduction to HypnoBirthing®

Balance is due in full at your first session by check or  cash unless other arrangements have been made prior. Balance paid by credit card or PayPal will incur $15 processing fee.

PLEASE NOTE:

For 2017 Private Hypnosis session fees are $147 initial visit [90 minutes], $97 per 60 minute follow up session.

Group class rate is the same price Debi paid in 2001 for only 10 hours of instruction, which included watching videos every session with no bonuses.

—————————————————————————————————————————————

Office use only:   

Sessions  

PROGRAM  

Group {3+}:   $97 per class [there are 5 classes]

Private {1}:   Please contact Debi directly for availability and fee

DATES  #1 ____________ #2 ____________ #3 ___________ #4 ____________ #5 _____________

TIMES

#1 ____________ #2 ____________ #3 ___________ #4 ____________ #5 _____________

Deposit due:  $97                 Deposit Due:  with completed paperwork

Deposit received: ___/___ /___ Check #: _______ Bank Name: ___________________or CC#______________________

Balance due: $_______ Balance Due:  1st session

Balance received: ___/___ /___ Check #: _______ Bank Name: ___________________

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