Guided by Glimmers APPLICATION FORM Looking to create a custom package to support you, please complete the application below and I will be in touch within 24 hours with next steps. CONTACT & BASIC INFO Name * First Name Last Name Partner's Name First Name Last Name Email * PHONE NUMBER * (###) ### #### LOCATION (City & state) * Estimated Due Date * MM DD YYYY Have you been pregnant before? * Yes No HAVE YOU GIVEN BIRTH BEFORE? * Yes No IF YES, WHAT WAS YOUR EXPERIENCE LIKE? YOUR VISION FOR BIRTH WHAT KIND OF BIRTH ARE YOU PLANNING? * Home Birth Birth Center Hospital Birth Not sure yet WHAT ARE THE TOP 3 THINGS YOU WANT FROM YOUR BIRTH EXPERIENCE? * WHAT ARE YOU MOST EXCITED ABOUT FOR YOUR BIRTH EXPERIENCE? * WHAT ARE YOU MOST NERVOUS/FEARFUL OF? * ARE YOU INTERESTED IN AN UNMEDICATED BIRTH? * Yes No Unsure ARE YOU OPEN TO ELECTIVE INDUCTION (NON MEDICAL REASONING)? Yes No Unsure WHAT'S ONE WORD OR FEELING YOU'D LIKE TO DESCRIBE YOUR BIRTH? * PARTNER INVOLVEMENT How would you describe your relationship as a couple, especially when navigating big transitions or decisions? * How involved would you like your partner to be during pregnancy, birth, and postpartum? * HEALTH & SUPPORT Do you have any current health concerns or conditions (physical, emotional, or spiritual) that you’d like me to be aware of? * What kind of support system do you have right now (family, friends, community)? * Have you worked with a doula, coach, or childbirth educator before? * Yes No IF YES, WHAT WAS YOUR EXPERIENCE LIKE? YOUR GLIMMER BIRTH PLAN What draws you to Glimmer Birth? * Which of these areas are you most excited to explore with support? (check all that apply) Mindset & mental preparation Pregnancy wellness & routines Natural birth education Partner coaching & support Postpartum planning & support All of the above WHAT, IF ANY, GLIMMER BIRTH PRODUCTS HAVE YOU ENJOYED? * Glimmer Birth Kit Mini Glimmer Guide Daily Glimmers Deck None of the above What do you hope to walk away with after working together? * THE DETAILS Which services are you interested in? (Check all that apply) * Full 1:1 Doula Support (virtual or in-person) Custom Glimmer Birth Plan Coaching Birth Prep Sessions for Couples Postpartum Planning Mindset & Advocacy Training Not sure yet - help me decide What’s your preferred method of communication? * Email Phone Voxer WhatsApp Zoom Is there anything else you’d like me to know about your journey, your story, or your heart? * Thank you for your application.I will be in touch within 24 hours with our next steps. Can’t wait to connect.
