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 *
Email *
Phone *
How did you hear about our program?
Birthday *
Address *
What county do you live in? *
What are your preferred pronouns?
Race or Ethnicity
Emergency Contact Name *
Emergency Contact Phone Number *
Which service(s) are you interested in receiving?
If you would like peer support what is your preferred method(s) of communication?
If you would like therapy do you need... *
If you are interested in professional therapy services, how much could you pay per session? Typically, we will offer scholarships for 8-16 sessions.
If you'd like therapy, what is your preferred language?
If you are interested in therapy, and if you are insured, what is your insurance provider?                             (Insurance is not required).
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?
Are you currently pregnant? If so, what is your due date?
Do you have any children, if so what ages & genders? Any other info you'd like to share about them?
What are your greatest joys of your parenting journey?
What are your greatest challenges of your parenting journey?
What do you like to do for fun or self-care? Do you have the time to do so?
Do you have any history of depression, anxiety or any other health related issues that we should know about?
Do you have a support system? Family or friends in town? Or afar?
How are you feeling right now?
Final thoughts: Is there anything else you want to let us know?
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