Support Group Questionnaire
Welcome to JC Lactation Counseling. To better serve you, please fill out the following survey. Once you submit this form, the confirmation page will contain the Stripe link to pay your fee. You will be signed up for the next group meeting!
Adres e-mail *
Are you lactating? *
When is your expected due date or your child's date of birth? *
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How did you learn about this support group? *
Consent for Group Attendance 
I understand that this support group is meant to provide me with information and education. Participation in this group does not create a clinical relationship between me and Janice Clarke, CLC.

I understand that I am responsible to consult with my primary care provider and/or my baby’s primary care
provider before taking action on anything that happens here today.
I recognize that Janice Clarke, CLC is not a doctor and cannot provide medical advice or supervision.

I recognized that if I have an established clinical relationship with Janice Clarke, CLC as my lactation counselor, it is up to me what I wish to share in the group setting about our prior clinical relationship. If I do reveal a clinical relationship, I understand that Janice Clarke, CLC will not make reference to our private clinical conversations in the group context, and will not provide me with specific or personal clinical recommendations or a plan of care.
Please type your name to give consent to join support group. *
You understand that deposits and fees paid for all provided services are non-refundable. Payment policy *
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