Perinatal Support Group Registration Form

Name of Parent/Guardian/Caregiver*

First NameLast Name

Name of Child(ren), if applicable*

Email Address*

example@example.com

Phone Number*

Please enter a valid phone number.

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.

Allergies/Sensitivities *

If none, please write N/A

Health Conditions*

If none, please write N/A

This program is for women and female-identifying folks (and their infants, if born) who are experiencing mental health challenges in the perinatal period and looking for additional support. Can you describe your experiences?*

If applicable, how old is your child?*

Our program is intended as facilitated and peer support, and we are not equipped as a team to offer acute crisis care. Can you describe the support you have received in this perinatal period?*

How would you describe your comfort level in discussing your feelings and needs with others? Is there anything about a group setting, or being in nature, that makes you uncomfortable or nervous?*

Are there any additional supports we can put in place to ensure you feel safe and at ease in our program?*

What do you hope to get from this program?*

Photo Consent Information

By providing photo consent, you agree that photos of you and/or your child(ren) may be taken and used by Playful Mindset for promotional purposes, including marketing materials, our website, and internal use. These photos will never be shared with third parties or used outside of our organization's official channels.

Photo Consent - please indicate whether or not you agree to give Playful Mindset photo consent:*

I AgreeI Do Not Agree

Program Evaluation Participation Information

Playful Mindset is conducting play-based evaluation to determine the efficacy of our programs. For example, we collect art, photo documentation, and stories from our programs as they're unfolding to share the impact of our work with families, funders and a wider research audience. No identifying information will be used in the process of our evaluation or reporting, (such as names or specific circumstances on why you've registered for our programs).

Program Evaluation Consent - please indicate whether or not you agree to participate in our program evaluation:*

I AgreeI Do Not Agree

Acknowledgement*

Playful Mindset Registration Form