Sample form from
Fearless Birthing

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Copyright Kim Wildner, 2003.
www.fearlessbirthing.com
Permission granted to copy this form for personal use only, as long as all copyright and contact informaion is included. May not be otherwise reproduced without permission of the author, nor may it be used outside of the Life Coaching for Fearless Birthing(TM) program without written permission from Kim Wildner, the originator of Fearless Birthing.(TM)


Goals and expectations:

What are your birthing objectives?

What are your parenting objectives?

What is your perception of your standing in relation to those stated objectives? What do you want to avoid or encounter?

What do you think may not be contributing to the positive outcome you seek?

Do you have a prior experience with unintended birthing/parenting outcomes? Or, do you perceive this as a problem based on the experience of other's outcomes?

Have you made attempts to solve the problem? If so, how? What happened?

Are there (were there) obstacles your attempts to a solution?

Are there obstacles to you implementing your consultant's suggestions?

How will you gauge your birthing/parenting "success"?

Is your entire birth team committed to making changes?

If not, are you willing to make changes to your birth team?

How do you see your role throughout the journey from what you see happening during your pregnancy(the possible problem) to what you desire for your birthing and parenting experience (the preferred outcome).

What sort of information and other support can you bring into your environment to support your efforts toward your desired outcome?

Rate the influence of the following people on your birthing decisions:

(highly influential) 1   2   3   4   5 (not influential at all)

Self         1  2  3  4  5

Husband         1  2  3  4  5

Family         1  2  3  4  5

Friends         1  2  3  4  5

Caregivers         1  2  3  4  5

Books         1  2  3  4 5

Internet         1  2  3  4  5

Television         1  2  3  4  5

Do you have personal birthing fears or parenting concerns?

On a scale of 1-10 with 1 being totally uninformed and 10 being very knowledgeable about pregnancy, birth and parenting, where are you? 1 2 3 4 5 6 7 8 9 10

On a scale of 1-10, with 1 being not at all and 10 being absolutely, how certain are you that your current thinking about pregnancy, birth and parenting is fact based? 1 2 3 4 5 6 7 8 9 10

Are you willing to test the veracity of your knowledge base?