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Question 1 of 13

Name

Question 2 of 13

Baby's birth date or due date

Question 3 of 13

Describe, in your own words, the struggles you are experiencing

Question 4 of 13

Please select any of the following symptoms you have recently experienced:

(Select all that apply)
A

Agitation

B

Irritability

C

Inability to sit still

D

Constant worry

E

Racing thoughts

F

Confusion

G

Excessive concern about baby or own health

H

On high alert

I

Appetite changes

J

Difficulty falling or staying asleep

K

Persistent gloomy mood

L

Sadness

M

Crying

N

Mood swings

O

Low self-esteem

P

Feelings of guilt or shame

Q

Loss of interest, joy, or pleasure

R

Poor concentration

S

Feelings of helplessness

T

Feelings of hopelessness

U

Feeling overwhelmed

V

Isolation or feelings of loneliness

W

Lack of feelings toward baby

X

Scary, worried, or intrusive thoughts

Y

Thoughts of self-harm

Z

Thoughts of harm toward baby

AA

Paranoia

AB

Hearing or seeing troublesome things

Question 5 of 13

What symptom is troubling you the most? 

Question 6 of 13

How well are you currently functioning on a scale of 0-10 (0 being not well at all and 10 being perfectly fine)?

Question 7 of 13

Please describe your goals in seeking support.

Question 8 of 13

Do you have any prior experience with mental health issues, personally or in your family (anxiety, depression, etc.), or do you have a history of trauma?  

Question 9 of 13

Have you previously experienced sensitivity to hormonal changes or do you have any endocrine dysfunction (thyroid disorder, etc.)? 

Question 10 of 13

Contact Info (email & phone number)

Question 11 of 13

Location (City, State)

Question 12 of 13

What is your availability for appointments? (best days, times) 

Question 13 of 13

How did you hear about us?

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