New Moms' Talk Group Mini-Questionnaire
Welcome!

Please fill out this mini-questionnaire so I can get to know you and your baby a bit before we begin.

For Chelsea, this form holds your space but official registration and payment is through Kids at Work's website.

For Inwood and Harlem locations, your registration is complete once you send in payment one of these methods:
• Chase QuickPay or Zelle (maryesthermalloy@gmail.com)
• Venmo (MaryEsther-Malloy)
• PayPal or PayPal Invoice (+ $6 service fee; maryesthermalloy@gmail.com)
• Check - if using this method, please email maryesthermalloy@gmail.com for address.

Thanks!

Mary Esther Malloy, MA

Mindful Birth NY
maryesthermalloy@gmail.com
347.276.2819
www.mindfulbirthny.com
Which sessions would you like to attend? *
Mom's Info
Mom's Name *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
Your Neighborhood
Your answer
Baby's Info
Baby's Name *
Your answer
Baby's Date of Birth *
MM
/
DD
/
YYYY
A few get-to-know you questions
Your responses can be super brief or pages long - however you would like to respond!
Why are you looking to join this talk group?
Your answer
How was your baby's birth?
Your answer
How was/is the early post-partum for you? (Challenges/things that have gone well)
Your answer
How is parenting going for you today?
Your answer
Any particular issues or topics you'd be interested to discuss?
Your answer
Missed session and refund policy *
Payment for the series is due before the first session, unless you make other arrangements with me. I can provide a full refund up to two weeks before the start date if I am able to fill your space; within the two week mark, I can provide a 50% refund if I am able to fill your space; otherwise, the fee is forfeited or credited to a future group. If you have to withdraw once the group has begun, I do not offer refunds but am happy to offer you a credit to future New Moms' Talk Groups. If you are joining us in Chelsea and have to miss a session, Kids at Work will offer you one make up in another of their drop in classes (music, etc). I do not offer refunds for your vacations, illness, out-of-town visitors, doctor appointments, etc. If I am called to a birth and have to reschedule a session, I will usually hold the make up the week following our regularly scheduled time, same day, time, location, etc. If you are unable to attend this make up, I will refund you the cost of this session.
Required
Payment Method - Inwood and Harlem Moms only (Chelsea Moms, please select top option) *
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