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Athens Parent Wellbeing Support
If you would like a peer support parent or to see a therapist please fill out this form completely. Thank you!
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Name
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Your answer
Email
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Your answer
Phone
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Your answer
How did you hear about our program?
Your answer
Birthday
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MM
/
DD
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YYYY
Address
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Your answer
What county do you live in?
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Your answer
What are your preferred pronouns?
They/Them/Theirs
She/Her/Hers
He/Him/His
Race or Ethnicity
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Phone Number
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Your answer
Which service(s) are you interested in receiving?
Peer Support (I would like to be matched up with a TheraMama or TheraPapa, a trained peer further along then you are in your parenting journey.) This program is free of charge.
Professional Therapy (I would like to go to counseling.) This program is pay what you are able per session, reBlossom with provide the remainder to the therapist.
Both services
Postpartum Doula (support in the home, baby soothing/parenting, breastfeeding, chores, childcare, parentcare). This program is free of charge and is available within 30 minutes of Clarke County..
Birth Doula (attending your birth & supporting you throughout.) This program costs you $250-400 sliding scale.
If you would like peer support what is your preferred method(s) of communication?
Phone Calls
Texts
Emails
Video Chats
In-person Visits
If you would like therapy do you need...
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In-person sessions
Telehealth (virtual) sessions
A combination of in-person & virtual sessions would be nice.
Childcare in our center
Required
If you are interested in professional therapy services, how much could you pay per session? Typically, we will offer scholarships for 8-16 sessions.
Your answer
If you'd like therapy, what is your preferred language?
Your answer
If you are interested in therapy, and if you are insured, what is your insurance provider? (Insurance is not required).
Your answer
If you are interested in our therapy program, which days of the week or times of the day would work for you to see a therapist?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Morning
Afternoon
Evening
Are you currently pregnant? If so, what is your due date?
Your answer
Do you have any children, if so what ages & genders? Any other info you'd like to share about them?
Your answer
What are your greatest joys of your parenting journey?
Your answer
What are your greatest challenges of your parenting journey?
Your answer
What do you like to do for fun or self-care? Do you have the time to do so?
Your answer
Do you have any history of depression, anxiety or any other health related issues that we should know about?
Your answer
Do you have a support system? Family or friends in town? Or afar?
Your answer
How are you feeling right now?
Your answer
Final thoughts: Is there anything else you want to let us know?
Your answer
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