The Mama Wellness Foundation Therapy Program

1

Name

First Name

Last Name

2

Email

example@example.com

3

Phone Number

Please enter a valid phone number.

5

What state are you currently located in?Please be mindful that we are currently only accepting mothers in LA and TX.

Texas

Louisiana

6

Are you able to participate in virtual sessions for 10 weeks over a 2-month period?

YESNO

7

Do you currently have a therapist?

YESNO

8

If not, have you ever had a therapist before?

YESNO

9

Can you share more about your support system?

10

Have you experienced any loss recently (death, job loss, friendships/relationships, etc)?

11

Do you have suicidal thoughts? Remember, The Mama Wellness Foundation does not treat any conditions. If yes, please seek immediate attention at the nearest hospital or contact the suicide hotline.

YESNO

12

Have you ever attempted suicide?

YESNO

13

Have you ever been hospitalized for an issue?

YESNO

14

Are you currently pregnant?

YESNO

15

If you’re not pregnant, how old is your youngest child?

16

Can you identify at least 1 area you would like support around during the 10 weeks of therapy (parenting, identity crisis, depression, relationship, etc)?

17

If selected, would you be interested in providing program feedback?This question does not determine eligibility.

YESNO

18

How can The Mama Wellness Foundation benefit you?

19

What do you hope to get from the organization?

20

Where did you learn about us?