Share Your Birth Story

First Name

Last Name

Email Address *

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Preferred method of contactEmailPhoneText

Are you 18 or older? *YesNo

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Please Note
This story form is currently limited to adults age 18 and older. If you are under 18, please do not continue at this time.

Story Interest

Did your birth experience include any of the following?Feeling unheardQuestions that were not fully answeredConfusion about care or next stepsUnexpected complicationsEmotional distress during or after birthConcerns about how I was treatedLanguage or communication barriersSomething else

In a few sentences, what part of your birth experience has stayed with you most?Please share only what you feel comfortable sharing at this stage.

Did you have the support of a doula or midwife?YesNo

Would you be available to create an audio recording of your story?YesNoI'm not sure

Optional Demographic Information

These questions are optional and are only meant to help us understand who is represented in the stories we receive.

CheckboxHow do you describe your race or ethnicity? Select all that apply.American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoMiddle Eastern or North AfricanNative Hawaiian or Pacific IslanderWhiteAnother race or ethnicityPrefer not to answer

What language do you mainly speak at home?

Please tell us your primary language

Consent

Disclaimer

By submitting this form, I understand and agree that I am voluntarily sharing only the information I feel comfortable providing.

I understand and agree that Altruism, Inc. may contact me using the preferred contact method I selected in this form.

I understand and agree that by submitting my story, I give Altruism, Inc. permission to review, use, reproduce, edit, adapt, publish, share, display, distribute, and otherwise use the story content I submit, in whole or in part, for project, promotional, fundraising, marketing, educational, editorial, advocacy, exhibition, and related organizational purposes, in any format or media.

I understand and agree that my submitted story may be used alone or together with visual, written, audio, digital, or other creative elements, including narration, voiceover, artistic interpretation, or likeness-based representation.

I understand that submission of my story does not guarantee that it will be used by Altruism, Inc.

I understand that this project is not providing medical advice, mental health care, legal advice, or emergency support, and I will not use this form to seek urgent help or report a medical emergency.

Disclaimer acknowledgement *I have read and understand the disclaimer above.Yes

Your Story Deserves Space