Postpartum Support Group Registration Form

Postpartum Support Group Registration Form

Intake Form
Please complete the following questions to sign up for our postpartum support group - all are welcome to attend. For more information, please contact Destinee at bmhcoordinator@birthworkersofcolor.com or 562-637-9023.

Meeting Location:

Our support group is hosted at our office located at 1635 E Anaheim St Suite A Long Beach CA 90813. If you need virtual support group options, please join us here - https://us06web.zoom.us/j/81557304979?pwd=FFn68HBFn83huGTQ81wxSFF0S7Uakm.1

**Postpartum Group offers wellness activities on the 3rd Friday of the month
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Pronouns

Other
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Are you currently on Probation?
Are you homeless?
Are you a Veteran?
Ethnicity/Background (select all that apply)

Other
Gender

Other
Postpartum Group Sessions ( please select all that you are registering for)
Do you have the ability to attend in person?
Would you like to attend virtually?
Do you need a ride to the group?
Are you a parent with a child under the age of three?

Other
When did you give birth?

MonthDayYear
Date
How confident do you feel in caring for your child(ren)?

1

2

3

4

5

1 is Not at all confident, 5 is Very Confident
In the past week, how often have you felt anxious or overwhelmed?
Did you have a postpartum visit with your care provider/doctor/OBGYN?

Other
Have you experienced any of the following postpartum challenges? (select all that apply)

Other
Do you have any questions or support needs? (ex. housing, lactation, nutrition, mental health therapy, etc)
Do you currently have a doula?
Are you interested in connecting with a no-cost birth/labor/or postpartum doula? ( Doulas offer emotional support, breastfeeding, education, advocacy, healing support, resources, more).
What type of doula support are you interested in? (Select all that apply)
Please share what you are looking for in a doula so we can match you with the best fit. Examples: Speaks a specific language, Cultural preferences, Spiritual or religious needs, LGBTQIA+ affirming support
Do you currently have health insurance?
What type of health insurance do you have?
How did you hear about our group?
Should be Empty: