Postpartum Parental Support Group Interest Form
This is a community oriented drop-in group that will provide a supportive and safe space for postpartum parents. You can share as much or as little as you feel comfortable. Listening with compassion is as valuable as sharing. Each week we focus on a theme, but you’re always welcome to bring what’s most present for you.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Have you participated in group therapy in the past?
Yes
No
What is your comfort level participating in group work?
Very comfortable
Somewhat comfortable
Neutral
Somewhat uncomfortable
Very uncomfortable
Are you currently seeing an individual therapist?
Yes
No
No, and I would like to be connected with a personal therapist at Your Next Chapter
This group will take place in person, at our office in the Montford neighborhood. Our group room is located on the third floor, which is only accessible by stairs. Would you be able to use the stairs to access this room?
Yes, I can access the third floor using stairs
No, I can not use the stairs to access the third floor
Each session is $10, but sliding scale is available based on household income. Do you need to apply for sliding scale to participate in this group?
Yes, I need financial assistance
No, I can pay $10 per session
What are your goals in joining this group?
Do you have any questions for the facilitator of this group?
Submit
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