New Mom's Support Group Registration Interview

How were you referred to this group?

How old is your baby?

What is his/her name?

Do you have other children?

Yes

No

Other

Are you currently under the care of a physician for medical reasons?

Yes

No

Are you or have you recently been concerned about the way you are feeling?

Yes

No

Have you been diagnosed with postpartum depression or anxiety?

Yes

No

Do you currently have a therapist?

Yes

No

The fee for group is $25/session, is this fee affordable?

Yes

No

What are you hoping to get from this group experience?