Would you like to serve as a peer support TheraParent volunteer?
We ask that you commit to a 9 am morning or 8 pm evening meeting every other month on the 3rd Tuesday to discuss how things are going and learn more about perinatal mental wellbeing. Meetings are hybrid and you can meet with us at ReBlossom or Zoom. In addition, you will be matched with one parent (or possibly two, if you want) who you check-in with on a regular basis to offer support via text, phone and/or in person, y'all decide.
What is your name?
Email
Phone Number
Birth Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name(s) & Age(s) of Child(ren)
1) Have you experienced any of the following and are you in a current place to assist/mentor someone who is experiencing something similar?
Premenstrual Dysphoric Disorder (PMDD)
Autoimmune Disorders
Endometriosis
Infertility
In Vitro Fertilization
Miscarriage
Stillbirth
Infant or Child Loss
Abortion/Termination
Adoption
Foster Child(ren)
Surrogacy/ Egg Donor
High Risk Pregnancy
Hypertension/Preeclampsia
Gestational Diabetes
Perinatal Depression/Anxiety or OCD
Preterm Labor
Bedrest
Premature Birth
NICU Stay
Medically Fragile Baby
Twins or Multiples
Infant Surgery
Hemorrhage
Birth Trauma
Past Sexual Abuse that is Triggered by Birth and/or Having a Child
C-Section
Emergency C-Section
Unmedicated Birth
Tearing
Hysterectomy
Pelvic Floor Rehab/Physical Therapy
Diastasis Recti Abdominal Separation
Postpartum Depression
Thoughts of Harming Yourself
Thoughts of Harming Your Baby
Anger/Rage
Loss of Appetite
Feeling Detached from Baby
Postpartum Anxiety
Panic Attacks, Dizziness or Tingling
Inability to Sit Still
Fear of Leaving the House
Fear of Being Left Alone with Infant
Fear of Separation
Fear of Death
Postpartum OCD
Intrusive or Racing Thoughts
Hypervigilance
Postpartum PTSD
Nightmares
Insomnia
Struggles with Baby's Sleep
Baby with Colic
Low Weight Gain
Financial Stress
Marital or Relationship Stress
Separation/Divorce
Moved Right Before or After Baby
Changed Job or Lost Job Before or After Baby
Staying at Home (we all know this is a full-time job)
Working Full-Time
Working Part-Time
Working From Home
Breastfed
Breastfed & Formula Fed
Formula Fed
Difficulty Latching
Baby with Tongue or Lip Tie Found & Clipped
Baby with Tongue or Lip Tie Discovered Late or Not Addressed
Mastitis and/or Plugged Ducts
Oversupply
Undersupply
Unplanned Switch to Formula
Exclusively Pumped
Baby Never Took a Bottle
Overall Positive Breastfeeding Experience
Overall Negative Breastfeeding Experience
Difficulty Weaning
Weaned Easily
Had PPD/PPA/PPOCD Symptoms After Weaning
Other
2) Is there anything that was not mentioned on the list that you would like to help with? Or have a unique experience with?
3) Would you prefer that we give out your email or phone number to a parent in need? We may also ask you to reach out directly.
Email
Phone
Both
Submit
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