APW Therapy Support Intake 2026

  • Athens Parent Wellbeing Support Intake

    This form is for those who are becoming parents or who are parents/caregivers who would like to ask for support and get connected with our services. This includes professional therapy matching and therapy scholarships. This form will take approximately 15-20 minutes to complete. Please visit our website to learn more. www.athensparentwellbeing.org

  • Disclaimer: At Athens Parent Wellbeing, we care about representing and addressing you correctly. Some of the questions in this form may feel more personal, but please know that both this form and our staff are HIPAA-compliant. HIPAA-compliant means your information is kept confidential and private. We encourage you to answer to the extent you feel comfortable. Your responses will help us connect you with the supports that best meet your needs.

  • Contact Information and Introduction

  • Format: (000) 000-0000.
  • What is your birthdate?*
     - -
  • What are your preferred pronouns?*
  • What is your preferred descriptor?*
  • How do you identify?

  • Section 1 of 4: Family Dynamics and Support. This section will ask you questions about you, your family, and sources of support. 

  • Where are you on your path to parenthood?*
  • In the previous question, you selected currently pregnant. When is your due date?
     - -
  • Please select what best describes your relationship status
  • A support system is a network of caring individuals in your life, such as a helpful family or friends, that encourage you. Do you feel like you have a support system?
  • Rows
  • Please select all who you consider in your support system.
  • Do any of the following apply to you or your family situation? Please check all that apply.
  • Do you have an open DFACS case or do you have past involvement with the Department of Family & Child Services?

  • Section 2 of 4: Access to Therapy and Mental Health Experiences. This section will ask you questions about your experiences with therapy and accessing mental health care. 

  • We aim to match clients with a therapist for therapy sessions on a sliding pay scale. Would you like to be matched with a therapist?
  • We believe everyone should be able to access affordable therapy. How much are you able to comfortably pay per therapy session without causing financial stress?
  • Do you have health insurance?
  • Would having a superbill be helpful for you in utilizing your insurance for care?
  • What form of therapy are you interested in?
  • We understand that your ability to attend therapy sessions may be dependent on childcare. Will you need child care? A handful of providers offer meetings at ReBlossom (located at 625 Barber St. #160), and center staff can provide childcare if necessary.
  • Do you have a preferred gender for your provider
  • What days are you available for your therapy session? Please check all available.
  • What general time blocks are you available for your therapy sesions?
  • Have you received professional help for your mental health?
  • We offer supplemental Peer Support Parent services through a Theraparent, who is a trained volunteer matched with you based on shared experiences to support you in your journey through parenting. Theraparents bring knowledge from lived experiences, from prenatal and/or postpartum mood disorders, infertility, loss, and everything in between. TheraParents are not therapists. Would you like to be matched with a Theraparent?
  • How would you like your theraparent to begin communication with you?
  • Are you currently experiencing, or have you experienced in the past month, any of the following symptoms or feelings (check all that apply)
  • Have you ever experienced any of these conditions? Please check all that apply.
  • When did you first notice symptoms?

  • Section 3 of 4: Demographics. This section will ask you questions about you and your background.

    Disclaimer: We want you to know that your responses are confidential and will be kept private. We collect this information to align our services with your needs and to understand the community we serve as a whole. Please answer to the extent you feel comfortable to do so.
  • What is your current work situation or main daily responsibility? Please select all that apply.
  • What is your race? You can select multiple that apply.*
  • Format: (000) 000-0000.

  • Section 4 of 4: Reflection. This section will provide you with an opportunity to share personal reflections and let us know anything additional you'd like to share which would be helpful for us to match you well.

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