2025 Virtual Postpartum Wellness & Connection Support Group Registration Form
Please complete this form to register for the Virtual Postpartum Wellness & Connection Support Group, which is held for 3-weeks on a Thursday for 90 minutes.

Also, please fill out our Pre-Survey Questionnaire.

Once we receive your submitted form, we will respond within 48 business hours with the link to your sessions. If you do not receive this, please contact us by email at info@mykotabear.com or call or text us at 1-888-695-6822.

Participants Overview: We are seeking individuals who are or are at risk for personally experiencing postpartum depression, anxiety, and mood disorders and need an outlet of support and resources to become better. 

Qualifications: 

  • Personal Experience: Does not have to be formally diagnosed with PMDD; the provider can refer to the group if within the postpartum period (within 24 months post-delivery)

  • Commitment: You must be willing to commit to attending the duration of the 3-week sessions. Cameras MUST be on at all times.

  • Respect and Confidentiality: Ability to keep discretion and respect for others' privacy. Approach discussions with sensitivity, understanding that each person’s journey with PPMD is unique.

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Email *
First Name *
Last Name *
Phone Number *
If you live in New Jersey, what county do you live in? 
If you do NOT live in New Jersey, please put the state that you live in.
*
What class are you registering for?
Classes are held on Thursdays from 12pm - 1:30pm
*
Required
Do you have multiples? (Twins, Triplets, etc.) *
Infant's Gender? *
How old is your baby? If you are pregnant, put "Pregnant" in the answer below. *
Pamper Size (Only select the size that you need NOW. We will NOT be able to supply you with all sizes for one child but check all that apply if you are requesting for more than one child.) *
Required
Child's clothing size? *
Required
How did you hear about this Postpartum Support Group? 
(If from a hospital, please list the name of the hospital. If a social worker, please name the person.)
May we add you to our (My Kota Bear & Therapy Story) email list? (We do not sell or share any contact information.) *
How many people live in your household? *

Gender;

*

Which category best describes your race?

*

Which of the following is a possible sign of postpartum depression? * (5 Points)

*

Unwanted thoughts can be increased by stress and anxiety. * (5 Points)

*

Who should a birthing person speak to if they are struggling with their mental health? * (5 Points)

*

Breastfeeding is easy because it is natural. 

*(5 Points)

*

What can a birthing person do to help take care of themselves emotionally?

* (5 Points)

*
Additional Information/Comments/Notes

I agree to the following Terms & Conditions:

Personal Experience: I am within 24 months post-delivery.  

Commitment: I commit to attending the duration of the 3-week sessions. My camera WILL be on at all times. 

Respect and Confidentiality:  I will keep discretion and respect for others' privacy, and approach discussions with sensitivity, understanding that each person’s journey with PPMD is unique.

Baby Supplies Disclaimer: My Kota Bear, Inc. receives diapers and baby supplies from organizations, individuals and businesses. My Kota Bear, Inc. & its affiliate partners are not responsible for any liability, loss, damages or expenses in connection with the use or the handling of diapers and baby supplies.  It is the responsibility of the recipient to inspect the diapers and baby supplies upon receipt. 

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Required
A copy of your responses will be emailed to the address you provided.
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