Feminine Bond Directory Practitioner RequestAll information provided in this form is for exclusive use of the Conservative Midwives Organization and will not be shared with third parties. Your Professional InformationYour Name *Keep me anonymous *YesNoIf you select "Yes", we will display your initials and certification in our directory instead of your name, and your business' contact information will not be shared. Clients will contact you through a representative of the Conservative Midwives Organization.Your Certification *Certified Midwife (CM)Certified Nurse-Midwife (CNM)Certified Professional Midwife (CPM) [*Only CPMs practicing in states where the CPM credential is legal will be added to the directory.]Licensed Midwife (LM)Lay Midwife [*Only lay midwives practicing in states where lay midwifery is legal will be added to the directory.]Non-U.S./International Midwife [Specify certification below]Women's Health Nurse Practitioner (WHNP)Obstetrician & Gynecologist (MD) [*Specify license status and board certification below]Certified Doula (CD-DONA)Other Doula Certification (specify below)Pospartum Certified Doula (PCD-DONA)International Board Certified Lactation Counselor (IBCLC)Other Certified Breastfeeding/Lactation Counselor (specify below)I can help conservative women in other ways (Specify your certification and services offered below)Mark all that apply. You don't need to disclose all your certifications, only the ones that you want women to contact you for. Certification details/other certificationsType here specifications about your certification and/or other certifications that are not listed above.Institution and year of certification *Institution - (YYYY)Organization, School, or Hospital that issued your primary certification and year of graduation/issue. This will NOT appear in your profile. Your PracticeContact information for clientsType of PracticeGroup practiceSolo practitioner Hospital affiliatedHome Birth PracticeBirth CenterHome visitsMark all that applyName of your practiceDisplayShow this name instead of the name I entered at the top of this form.Show both, this name and the name I entered at the top of this form.Do not show this name on my profile.How your name will appear in your profilePractice Location *County where you are based or Street Address of your practiceStateState where your are currently practicing. Type "none" if you practice outside of the United States.Practice ZIP codeCountry Select countryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweIf Non-U.S./International practitionerPhoneEmail AddressWebsite(Optional) Profile pictureChoose FileNo file chosenDelete uploaded fileSubmit a picture of yourself, your practice group, or your logo. Bio (Optional)Add information to help clients know more about you and your practice. Client PreferencesThis information will help us match the right clients with the right providers.Do you offer any of these services?Full-scope MidwiferyWell-Woman CarePrimary CareGynecologyObstetricsPrenatal UltrasoundFertility TreatmentsWater BirthChildbirth EducationBreech External InversionVaginal Breech BirthVBACCesarean/Cesarean First AssistNewborn CircumcisionWell Newborn CareVaginal Twins Birth IUD insertionHypnobirthHolistic MidwiferyMark all that apply(Optional) Other servicesList any other services that you would like us to include in your profile. Do you have any of these certifications active? (Mark all that apply)BLSALSACLSNRPNoLanguagesEnglishSpanishOtherLanguages spoken in your practice.Your/Your practice's religious affiliation (s) (This is important for some clients)NonePrefer not to discloseChristian (non-Catholic)CatholicConservative or Reform JewishOrthodox JewishLatter-Day SaintMuslimOtherMark all that apply. CMO MembershipBecome a professional member of the Conservative Midwives Organization. FREE through November 2021.Choose one *Please enroll me as a member of the CMO. I would like to receive more information about the CMO before I enroll. I am not interested in joining the CMO.We can review the information on this form to determine if you are eligible to become a professional member of the Conservative Midwives OrganizationTerms and ConditionsRead and mark all to agree with the terms and conditions *I certify that the information provided above is true and that I am the person represented in this profile. I authorize the Conservative Midwives Organization to share my practice's contact information publicly if I did not choose the option of an anonymous profile. I am aware of the information that will be shared in conservativemidwives.org as well as the information that will be kept private.I understand that my information will be reviewed by the CMO Board, that I might be contacted to provide additional information related to my professional licensing, and that my request will be rejected if I don't meet legal criteria as a practitioner.I authorize the Conservative Midwives Organization to contact me for client requests if my profile is anonymous. Your request will be rejected if not all terms and conditions are marked. Your email *Type your email again or insert a different one for us to contact you. Send Message