Mom.ME. Cares Therapeutic Program
2nd Cohort July 1, 2022 - June 30, 2023
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Email *
Let us walk through the darkness with you.....
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First Name: *
Last Name: *
Date of Birth: *
MM
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DD
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YYYY
Contact Number: *
Address: *
City: *
State: *
Zip: *
County: *
Employment: *
Position:
Salary: *
How did you learn about the Cares Therapeutic Program:
Demographics: (Optional)
This section is OPTIONAL, but the information will help us make the best match between you and a therapist.  This information will only be used by Mom.ME. and will never be shared with an outside source without your approval.
How would you describe your gender: *
Race/Ethnicity: *
Marital Status *
Do you currently have medical insurance coverage? *
If yes, please what is your Insurance Provider's Name: (insurance card required)
Do you have maternal mental health coverage? *
Do you currently receive federal assistance? (check all that applies) *
Required
How many children do you have? *
What are their ages: (check all that apply)
Child 1
Child 2
Child 3
Child 4
Child 5+
0-3 months
3-6 months
6-12 months
13+ months(1 yr)
2 years old
3 years old
4 years old
5 years old
6 years old
7 years old
8 years old
9 years old
10+ years old
Clear selection
Are you or your partner currently pregnant? *
If yes, what is the due date:
MM
/
DD
/
YYYY
Physician's name:
Physician's Phone:
Are you a parent of multiples: *
Did you or your partner experience pregnancy or post birth health complications: *
If yes,  please describe:
Do you identify as a NICU parent: *
Did you or your partner go through infertility treatments:
Clear selection
Have you or your partner suffered a pregnancy or infant loss:
Clear selection
Have you ever served or are currently serving in the Armed Forces (U.S. Military) *
If yes, which branch:
Clear selection
Perinatal Mood Disorder Information (Perinatal Mood Disorders)
This section is OPTIONAL, but the information will help us make the best match between Mentor and Peer.  This information will only be used by Mom.ME. and will never be shared with an outside source.
Have you or a family member ever suffered from a mental health disorder in the past? (i. depression, anxiety, bipolar, etc.) *
If yes, please describe:
Even if you have not been officially diagnosed, do you believe you are suffering from a Perinatal Mood Disorder (PMD): *
If yes, which PMD(s) are you affected by: (please check all that apply)
If you selected other above, please describe:
Are you experiencing any of the following symptoms: (please check all that apply) *
Required
If you selected other above, please describe:
If you are suffering with a maternal mental health disorder (Perinatal Mood Disorder), where are you in your recovery process: *
If you have fully recovered, how long have you been recovered:
Clear selection
Do you currently use medication as a part of your recovery: *
Do you currently see a therapist/counselor as part of your recovery: *
Are you currently or have you ever participated in any of the following programs: (check all that may apply) *
Required
If you selected other above, please describe:
Are you currently or have you previously used any of the Mom.ME. resources to help you through your PMAD: (check all that apply) *
Required
If you selected other above, please describe:
Do you currently have plans of breastfeeding, formula feeding or tube feeding:
Clear selection
If you are currently or have recently in the past  breastfed, for how long?
Clear selection
What did/do you like to do in your spare time:
Program Specific Questions (Required)
The following answers will further assist our Care Coordinators in helping refer you to the appropriate Counselor/Therapist. This section is required.
Who's your current support system: (check all that apply) *
Required
If you selected other above, please describe:
Is there a specific goal you would like to achieve while in the program: *
Are you willing to communicate via texting or phone calls with your Mom.ME. Care Coordinator and/or Therapist at least ONCE per week: *
Are you currently participating in online or in-person or  support groups: *
Are you currently participating in therapy/counseling of any kind? *
Do you consider yourself to be more of and Extrovert or Introvert?
Clear selection
Emergency Contact
Your privacy is as important to us as your emotional well-being. We do require an emergency contact #, but would only use it in a real or perceived emergency.
Name of Contact: *
Phone #: *
Relationship to you: *
I give Mom.ME. permission to contact the person listed above in the event of a crisis or emergency on my behalf: (whether actual or perceived emergency) *
Application Agreement
By submitting this application, I certify that the information above is correct to the best of my knowledge.
I agree to follow the requirements and policies set forth by the Mom.ME. Pilot Care Program: *
Required
I agree to participate in phone calls and respond to text messages from my Care Coordinator and/or Therapist in a timely manner: *
I understand that submitting this application does not guarantee me a spot in this program.   *
Thank You
Mom.ME.
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