We’d Like to Get to Know You…

The following questions will help your facilitator get to know you and provide the best experience for your pod. Please answer as fully as you can and know that your confidentiality is of the utmost importance to us. If you would prefer to talk to us over the phone instead, just email us instead.

Mom Pod Intake Questionnaire

Mom Pods Post-Registration Survey Form

Name

First Name

Last Name

Age

Number of children

Youngest child's birthday or due date

YYYY

Who lives in your home?

What is your relationship status?

Are you working now or planning to work while you have a child under 2?

If you have experienced any trauma, mental health disorders, or find any topics to be triggering, please inform your facilitator using this form, so she can be sensitive to your needs. If you would prefer to talk to her one-on-one, please note that here.

What made you decide to join a Mom Pod? What are you hoping to gain?

What qualities are you looking for in a facilitator?

What qualities are you looking for in your pod mates?

Is there anything else you'd like your facilitator to know about you? Would you like a phone call with her before the sessions begin?

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Three adjectives that describe you today

Want to give the Gift of Support to a family who needs it?

Help us offer free services to a birthing person from a marginalized group (BIPOC, LGBTQIA+, or low-income) by donating to our Birth Justice Fund. Email or text us for details.

Back To You Support

info@backtoyousupport.com

815-242-2240 text

Offering Support Nationwide

In-Person Services in Northern Illinois and Southern Wisconsin

Interview with the Founder