Register for Chime (postpartum) Name * First Name Last Name Email * Your Date of Birth MM DD YYYY City where you currently live * Best # to reach you * (###) ### #### Can I leave confidential voicemail or text messages at the above number? * Yes No Emergency Contact - Name Emergency Contact - Relationship Emergency Contact - Phone Number (###) ### #### Who referred you to The Workshop? Your past experience (if any) with Mindfulness Your past experience (if any) with therapy / any history of mental health challenges Are you currently in therapy? Yes No Your baby's name (& nickname if applicable) Your baby's date of birth MM DD YYYY Your estimated due date was/is Place of birth (specific hospital or at home/ attended by…?) Any birth complications Approximate length of labor Do you feel that your birth was positive/mixed/ traumatic? / How would you describe your birth experience? Do you currently think you are depressed? What kind of familial/friend/social support do you have around now for you? What number birth was this for you/How many children do you have? Have you experienced miscarriages or still births and if so how many and what were the approximate dates of those losses? What are you most looking forward to about this postpartum few months and what are you most concerned about? What you are most hoping to get out of this group: Thanks, your responses have been submitted.
