Postpartum Support Group Registration

Postpartum Support Group Registration

Please note all answers are protected health information and are kept confidential.
A note from Nicole Malcolm, LCSW, PMH-C:

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me, and you can reach me at the contact information below. Please read and indicate that you have reviewed this information and agree to it by signing at the end of this document.

3littlebirdsresources@gmail.com
(516) 900-3958
Name

First NameLast Name
Your Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Person:

First NameLast Name
Emergency Contact Number:
Please enter a valid phone number.
Emergency Contact Email:
example@example.com
Emergency Contact's Relation to You:
Please note, your emergency contact person will only be contacted in the event of an actual emergency.
Date of your expected birth:

MonthDayYear
Date
Briefly describe your most recent birth experience:
Briefly describe any other pregnancies and deliveries you’ve experienced. If this is your first birth experience please respond “N/A”:
Do you have any medical conditions?

YesNo
If yes, please describe:
Are you currently prescribed any medication for a medical or mental health condition?

YesNo
If yes, what medications have been prescribed:
Who resides in your home with you?
Briefly describe what you are hoping to obtain from participating in this group:
Confidentiality
The session content and all relevant materials to the your treatment will be held confidential unless you request in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:
- If you threaten or attempt to complete suicide or otherwise conduct yourself in a manner in which there is a substantial risk of incurring serious bodily harm.
- If you threaten grave bodily harm or death to another person.
- If the therapist has a reasonable suspicion that you or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
- Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
- Suspected neglect of the parties listed above.
- If a court of law issues a legitimate subpoena for information stated on the subpoena.
- If you are in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an expert’s report to an attorney.
- If we see each other accidentally outside ofthe support group office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapeutic space.
BY SIGNING BELOW I AM AGREEING THAT I HAVEREAD, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT

Clear
Please note that this series takes place over the course of 6 weeks, meeting virtually every Sunday starting January 15th, 2023. There are no refunds available if you have missed a session. If you need financial support to attend this series, please reach out to us at info@birthandbeyondresources.com.
Investment for 6 week series:

prevnext( X )
USDDescription
Should be Empty:

Postpartum Support Group Registration

Confidentiality