During the COVID-19 health crisis, many groups will be online. We ask that you read and copy/complete the following form and email it to the contact listed for the group you are attending.

THANK YOU and WE LOOK FORWARD TO MEETING YOU

Name: ________________________________________________________________

Name/Age of Children: _______________________________________________

Address: _______________________________________________________________

Cell Phone: ____________________________________________________________

Emergency Contact: ___________________________________________________

Emergency Contact’s Cell Phone: _______________________________________

Partner/ Spouse: _______________________________________________________

Email: __________________________________________________________________

Therapist/Psychiatrist: _________________________________________________

This is a perinatal support group for members’ mutual benefit. It is to help those who are experiencing difficulties adjusting to the perinatal experience and/or a perinatal mood disorder. This online group is not group therapy or counseling, and it is not a substitute for mental health treatment. If you feel you may require additional support and/or a referral to a medical or mental health provider, please speak with one of the facilitators, who will be glad to help you find resources.

The purpose of the group is to create a non-judgmental environment where we can share thoughts and feelings, talk about challenges, receive support, and obtain information about perinatal disorders. Our mission is to empower and provide hope during the recovery period. To foster a safe and supportive environment, we ask that all members abide by these guidelines:

*Whatever is shared in the group, stays in the group. Keep it all confidential. Find a private space and secure internet service when joining the group online.

*We have no “camps” (i.e. breastfeeding vs. Bottle-feeding, stay-at-home vs. paid employment, etc.). We respect whatever works for one may not work for another. This circle isn’t a place to give advice. If asked, we may suggest ideas based on what has worked for us in the past, without pushing ideas on others.

*Babies are welcome, (and everything baby-feeding, changing, soothing!) though you are also welcome to come alone.

*To protect the privacy of other group members, we ask that family members and friends not attend.

Support group conversations are confidential. However the group’s leaders will contact my emergency contact, physician &/or therapist if I appear at risk of harming myself or someone else. By including my email address, I agree to receive reminders/notifications about the circle from time to time. I have read the above and agree to abide by them while participating in this support group.

___________________________________________ ____________________________ Signature Date