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ICAN of Phoenix Member Survey
In order to protect the safety and culture of our ICAN of Phoenix group, we ask that each member of our private community fill out the following survey. This survey will help us understand the unique needs of our group, will give us a better understanding of our collective experiences and will help us ensure that each member is there to recieve or provide cesarean awareness and birth support.
The fields marked with an
*
are mandatory and exist to ensure the security of the group. All other fields are optional, but will help us gain a better understanding of the needs and experiences of our members.
Thank you for your understanding and your participation.
Name (As it appears in Facebook)
*
First
Last
How did you hear about ICAN?
*
Internet Search
Brouchure, Pamphlet, Business Cards, etc.
Friend
Other
If Other please specify:
*
Are you a paid subscriber of ICAN?
*
Yes, my subscription is currently active.
I have previously subscribed, but it has been greater than a year.
I have never been a subscriber.
Your Birth Experience
Please fill out which of the following births you have personally experienced:
*
Vaginal Birth
Cesarean Birth
Vaginal Birth After Cesarean (VBAC)
Repeat Cesarean (Planned or Unplanned)
Currently pregnant; no previous births
No personal birth experience; please leave a comment below
If you are not pregnant and have no previous births, please briefly explain why you are interested in joining the ICAN of Phoenix group.
*
How many previous cesareans have you had?
*
None
1
2
3+
How many vbacs have you had?
*
None
1
2
3+
Are you currently pregnant?
*
Yes (Please select your EDD below)
No
Estimated Due Date
*
Care Provider Recommendations
*Optional*
We would like to know if you have any prenatal/postnatal care providers in the greater Phoenix area that you would recommend based on your direct experience working with them. By listing the names below, you are stating that you have used that individual for prenatal or postnatal care and would recommend their services to others. The information collected in this field may be used for the ICAN of Phoenix Resource Directory; your recommendation will remain anonymous. Each field is optional.
Recommended Obstetrician
*
Recommended Midwife
*
Recommended Doula
*
Recommended Child Birth Educator or Class
*
Recommended Hospital (Arizona Only)
*
Are you a Care Provider?
What type of care provider are you?
*
If you would like your services to be considered for our resource page, please fill out the information below.
Name of Business (if applicable)
*
Contact Number
*
-
-
Contact Email
*
Business Address (if applicable)
*
Line 1
Line 2
City
State
Zip Code
Country
Information about your services:
*
Contact Information
Periodically, ICAN of Phoenix may send emails or physical mail to communicate ICAN news. If you are interested in recieving these communications, please fill out the information below accordingly.
Email (Optional)
*
Phone Number (Optional)
*
-
-
Address (Optional)
*
Line 1
Line 2
City
State
Zip Code
Country
Submit