Mama Birds Well & Wild Child, LLC: Intake Form

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Welcome to Well and Wild Child, LLC! We are so excited for you to join us and learn more about supporting yourselves and your child! We are going to have so much fun! Let's get started...

The goal of this program is to support and empower mothers on their journey of motherhood, or matrescence. The word matrescence means the phase of life when a woman transitions into motherhood. We all know how vulnerable, raw and transformative this time in a woman's life can be. With Mama-birds, I am striving to leave mothers feeling educated, connected and confident during this period of time.

Mama-birds is intended for mothers and infants ages 0-12 months.
This 5-week Mama-birds series will focus on the following goals:
-teaching moms practical strategies for supporting the development of their baby at their current age/stage, provide opportunities to educate mom on developmental milestones & the confidence to support them with hands on strategies.
-providing mom with opportunities to practice a variety of positioning and handling techniques with their little one; from wearing baby, to tummy time, feeding and more
-educating mom in guest-expert areas of lactation/feeding, pelvic floor and postpartum mental health support & providing tips/strategies for carryover
-myth busting common misconceptions
-parenting through co-regulation and connection
-providing a sense of community in person

Please fill out one form per mama & infant- for questions, please email Jenna@wellwildchildot.com

Mama Bird & Hatchlings
Dates: April 25, May 2, 9, 16, 23
Investment: $12/session (info listed below in payment section)
Location: 400 West 5th Street Jamestown NY
Time: 4:00-5:15 pm

Important* this program is being offered on a first come, first serve basis!
This round of Mama-birds will only be offered at this low price of $12/session just this once!
All other Mama-bird programs hereafter May 23, 2024 will be offered at a different cost.

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Электронная почта *

Please list a name and phone number for an Emergency Contact: *

Would you like to be added to our email list to be the first to know about future programs? *

Yes

Already on the list!

Enter your email address below. *

Child's Full Name *

Child's Birthdate *

Child's Age

Parent(s) Name(s) *

Address *

Parent(s) Phone(s) *

Did your pregnancy go to full term (40+) weeks? *

Yes

If you answered NO to the above question, please list the amount of weeks your child was premature. This allows me to have a better understanding of the gestational age and development of your child. If this does not pertain to you, type 0 *

Please throughly explain any complicated medical history that occurred during pregnancy, during labor and after birth for YOU. Type N/A if not applicable or you do not wish to answer this question.
*

Please throughly explain any complicated medical/birth history that occurred during pregnancy, during labor and after birth for your BABY. Please include NICU stays if applicable. Type N/A if not applicable or you do not wish to answer this question. *

Has your child been diagnosed with: *

Dyspraxia or Developmental Coordination Disorder

Congenital Disability

Developmental Disability

Physical or developmental challenges

Medical conditions or issues

Heart problems

Asthma

Food allergies

None of the above

Обязательный вопрос

Please thoroughly explain any health or developmental issue checked above or type N/A: *

Please list any other significant medical history that may impact participation or safety for you or your infant: *

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