Athens Parent Wellbeing Support Form
This form is intended for parents and caregivers to ask for support in the areas of professional therapy matching and scholarship services and/or peer support parent mentorship. Please visit athensparentwellbeing.org to learn more.
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What county do you live in?
Phone Number
Please enter a valid phone number.
My Birthdate
-
Month
-
Day
Year
Date
How did you hear about our program?
Where do you work or what do you do, and how many hours a week?
Children's Ages & Names
Are you currently pregnant? If so, what is your due date?
What are your preffered pronouns?
They/Them
She/Her
He/Him
Your Race/Ethnicity
Your Emergency Contact's Name
First Name
Last Name
Your Emergency Contact's Phone Number
Please enter a valid phone number.
I would like to be matched with a professional therapist. This is a pay-what-you-are-able to service for up to 12 sessions.
Yes
Not right now
How much am I able to comfortably pay per therapy session? We believe everyone should be able to access mental health therapy and do not want it to become a stressor.
What form of therapy do I need?
In Person Sessions (I will go to their office)
Telehealth (virtually on the computer from my home or workplace)
Don't have a strong preference
I would like in person, but need on-site childcare (at ReBlossom 625 Barber St. #160)
What language would you like therapy in? English, Spanish or French
If you have insurance, what is your provider? (It is not necessary).
When do you need therapy?
Mornings
Afternoons
Evenings
During the week
On the weekend
I would like to have a Peer Support Parent assigned to me. A Theraparent is a parent and a trained volunteer who is a survivor of prenatal or postpartum mood and anxiety disorders who wants to assist your transition.
Yes
Not right now
How would I like my theraparent to begin communicating with me?
Email
Phone Conversation
Text
In-person
I do not want peer support at this time.
What are your greatest joys of your parenting journey?
What are your greatest challenges in your parenting experience?
What do you like to do for fun or self-care? Do you have the time to do so?
Do you have a support system? Family or friends in town? Or afar?
How are you feeling right now?
Do you have any history of depression, anxiety or any other health related issues that we should know about?
Do you have an open DFACS case or do you have past involvement with the Department of Family & Child Services?
Yes, I have an open case now.
Yes, I have past involvement.
No, I have never had involvement with DFACS in our state or others.
Final thoughts: Is there anything else you want to let us know?
1) I understand that if I am signing up for therapy I will respond to my therapist when they contact me. I will not be unresponsive and I will show up to my appointments. If I do not show up without letting them know, I may be forfeiting my scholarship. If I am signing up for peer support, I will respond to my TheraParent, because they are kind humans who volunteer their time for you.
2) I understand that if I may be suicidal or if I am worried I may harm my child(ren) there are emergency services available with the all-hours Georgia Crisis & Access Line 1-800-715-4225. Postpartum Support International (www.postpartum.net) has a warm line 1-800-944-4773. Athens Parent Wellbeing & its members, your therapist, peer support parent and their team will not be held liable in any way for risk, danger, injury, damages or harm to you or your family. Please sign if you agree.
3) We value your privacy and your individual relationship with your therapist, and theraparent, however we also know that your support people may need some support in supporting you, so they may reach out to our team to gather more resources or strategies for you as a parent. Please know that we have your wellbeing at heart. Please sign below if you understand.
Therapist Name
Therapist Email
example@example.com
Match Date
-
Month
-
Day
Year
Date
Session Count
Status
Please Select
Active
Paused
Completed
4) NOTICE OF PRIVACY PRACTICES Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. I. Athens Parent Wellbeing understands that health information about you is personal. We use HIPAA-compliant Jotforms to house your protected health information (PHI) and those who are handling these forms are HIPAA-awareness trained. II. I permit APW to share PHI with your matched therapist, peer support parent, coach, doula or group facilitator and for them to share information back to us, including appointment times & payment information. III. APW will not use or disclose your PHI for marketing purposes and will not sell your PHI. IV. I agree to give APW permission to contact the emergency contact listed above in case of an emergency, in which some PHI could be disclosed. V. APW can only disclose your PHI without your authorization when disclosure is required by judicial proceedings, audits, law enforcement purposes, coroners or MEs, workers' compensation laws, state or federal law, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety. VI. You have the right to ask APW not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request if APW believes it would affect your health care. VII. You have the right to get a paper or electronic copy of this notice or PHI that we have on file for you within 30 days of a request. VIII. You have the right to correct or update your PHI, and at any time you can fill this same form out again to update it (address changes, phone number changes, etc.).
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