Supporting Mothers

Blooming Families

Supporting Mothers
Please take a few minutes to complete this form as thoroughly as possible so I can better support you.
SECTION 1: Basic Information
1. Name

First NameLast Name
2. Email
example@example.com
3. Age Range

45 -5051- 6061- 6566+
4. What is your marital status?

Married/PartneredDivorce/SeparatedWidowed
- SECTION 2: Your Current Season
- 5. Which of the following best describes what you are experiencing?
  
  Anxiety or low moodEmpty nest syndromeEstrangement from an adult childFeeling guilt or shame about past parentingIdentity shift after children leaving homeLimited or reduced contactLonelinessLoss of purposeOngoing conflict with an adult childRelationship strain with partner
- Other (please specify)
- 6. How long have you been feeling this way?
  
  Less than 6 months6–12 months1–3 years3+ years
- 7. On a scale of 1–10, how emotionally overwhelmed do you feel right now? (1 = calm / 10 = extremely overwhelmed).
- SECTION 3: Your Relationship With Your Adult Child
- 8. What is the current status of your relationship with your adult child?
  
  Close and connectedEmotionally distantLimited contactSome tension but still communicatingNo contact (estranged)
- 9. If you feel comfortable, briefly describe what led to the current situation.
- 10. What feels most painful right now?
- 11. What have you already tried to improve or repair the relationship?
- 12. What outcome would you hope for, if healing were possible?
- SECTION 4: Identity & Emotional Landscape
- 13. When you think about this stage of life, what thoughts come up most often?
- 14. Do you struggle with guilt or self-blame regarding your parenting?
  
  OftenSometimesRarelyNot at all
- 15. What emotions do you experience most frequently right now?*
  
  AngerConfusionFearGriefHopeLonlinessNumbnessRegretReliefShame
- 16. Outside of being a mother, how connected do you feel to your identity?
  
  Very disconnectedSomewhat disconnectedSomewhat connectedStrong sense of identity
- 17. What parts of yourself feel lost or neglected?
- SECTION 5: Patterns & Awareness
- 18. Growing up, how were emotions handled in your family?
  
  Openly discussedAvoidedDismissedCriticisedUnsure
- 19. Do you recognise any repeating patterns between your upbringing and your parenting?
- 20. When conflict happens, do you tend to:
  
  Over-explainWithdrawBecome defensiveTry to fix everythingAvoid confrontationOver-apologiseOther
- SECTION 6: Your Readiness for Change
- 21. What would feel different in your life if you felt emotionally at peace?
- 22. What kind of support are you looking for right now?
  
  Boundaries & relationship repairCommunication toolsEmotional processing & grief supportEstrangement healing guidanceIdentity & purpose coachingNot sure yet
- 23. On a scale from 1 to 10, how prepared are you to take action and create change?
- 24. Is there anything else you would like me to know before our call?
- 25. Are you prepared to invest time and emotional energy into this work?
  
  YesI believe soI am unsure
- 26. If we decide to work together, are you in a position to invest financially in support?
  
  YesPossiblyI need more information
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Blooming Families

SECTION 1: Basic Information