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BA NIA Interest Form
Please fill out this form when first meeting with a potential BA NIA client. This form is brief and informal and its purpose is to get to know the potential client.
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* Indicates required question
First name
*
Your answer
Last name
*
Your answer
Preferred name (if applicable)
Your answer
Pronouns (select all that apply)
*
She/her
He/his
Them/they
No preference
Other:
Required
Preferred email
*
Your answer
Cell Phone Number
Your answer
Story (e.g., challenges with previous pregnancy, goals with current pregnancy, hopes/fears about pregnancy and birth)
*
Your answer
Services of interest
*
Childbirth Education
Prenatal and Postpartum Yoga
Birthing Assistance
Postpartum Support Specialist
Breastfeeding Support
Infant Massage
Right of Passage
Required
How did you hear about us?
*
Your answer
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