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T1D & Autoimmune Concierge Maternal Healthcare Program Application
**PLEASE READ THIS FIRST**

Hey Future Mama!

We're so glad you decided to apply and we can't wait to support you throughout your pregnancy, birth, postpartum, and breastfeeding journey.

*Please fill this out completely and honestly WITH YOUR PARTNER. There are no wrong answers! ​

Why an application? We are looking to broaden our community with future Mamas who are COMMITTED to pursuing positive change for THEIR BABY & THEMSELVES. This is a transformative program with a high-level investment, therefore we want to make sure that all mamas who are invited to enroll are a good fit.

Why with your partner (if applicable)? We KNOW that both partners MUST be involved every step of the way for the maximum transformation! 'It takes a village' - and it starts with you BOTH.

*ONLY fill out this application if you are willing to invest in your health and your baby's health.

We understand that start times for support in this journey may vary from Mama to Mama, however we see the most success with individualized goals when we work with our clients throughout pregnancy, up to ~3-6 months postpartum.  

After you and your partner submit your application, we will connect with you to set up a Free Consultation call to talk about your application and figure out which program would be a good fit.

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Email *
Name & Partner's Name (if applicable) *
Phone Number: *
Are you applying while... *
Mama: Tell us about yourself and your current reality within the maternal journey (number one goals, health fears, unrelated health fears, major stressors, your current struggles, etc). We want to hear it all!   *
Partner: What are your thoughts about your partner's journey (Fears, wishes, stressors, aspects you see from your perspective and wish to share, etc.)? How involved are you in helping your partner achieve her ('your' - as a couple) pregnancy goals? We want to hear from YOU!
Mama:  What is your #1 health goal you would like to accomplish in the next 12 months? What is your DESIRED situation? (health, prep for birthing and breastfeeding, lifestyle, stress management?) *
Mama: Be Honest - what do you think is stopping you from reaching this goal on your own? (The more specific you are the more we can help you!) *
Mama: What do you believe makes us a good fit to work together? *
Partner: What do you believe makes us a good fit to work with your Mama-to-be?
Mama: Have you ever invested in an T1D/autoimmune related program before? What was your experience? *
Our programs are private pay. Are you prepared to invest at this level and show up to achieve your goals? Prices range from $500.00 - $8,494.00 depending on support level provided and length of contract. *
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