Thank you (Bringing Baby Home)

Bringing Baby Home Intake Form (#4)

Mom’s/birthing person’s Info

Please answer each question.

Mom’s/birthing person’s full name

Mom’s/Birthing Person’s Phone Number

Mom’s/Birthing Person’s Date of birth

Mom’s/Birthing Person Email Address

Mom’s/birthing person’s Gender

Mom’s/Birthing Person’s Occupation

Mom’s/Birthing Person’s Address

Address Line 1

Address Line 2

City

State

Zip Code

Estimated due date OR date of birth for child (under 3 years old)

Mom’s/birthing person’s History: what baby/birth is this for you?

Any comments?

Partner’s Information

Please answer each question for the partner/other parent who will be attending the group.

Partner’s Full Name

Partner’s Phone number

Partner’s Date of Birth

Partner’s Email Address

Partner’s Occupation

Partner’s Gender

Partner’s Address same as Mom’s/Birthing Person’s Address

Yes

Partner’s Address

Address Line 1

Address Line 2

City

State

Zip Code

Partner’s history: what baby/birth is this for you?

Any Comments?

Tell us a little more…

Please answer each of the questions in this section.

Your agreements

Disclaimer and Confidentiality agreement:

Confidentiality. Clients have a right to expect that information revealed to your therapist will not be disclosed to any other persons without extraordinary justification. The conditions that justify the release of information and by law must be reported to the appropriate agencies are the following:
• Knowledge of child abuse or neglect of a minor currently under age 18.
• Knowledge of senior citizen abuse or neglect.
• Knowledge of a felony that has been or is being committed.
• A client who poses a serious risk of suicide and is an imminent danger to self.
• A client who poses a threat of imminent danger to another person.
• A judge, by issuance of a court order, may obtain information. In all other situations, signed authorization by the client for the release of information is required. (See HIPAA privacy policy disclosure below.)
Group disclaimer. Disclosures by any member of the group should be considered confidential by all other members of the group. However, the instructor or therapist is not responsible for confidentiality breaches by group members, bystanders, guests, or any other entity.
Not therapy. I understand that the services provided to me are for educational and self-improvement purposes and are not for the diagnosis or treatment of any mental or physical ailment. I understand that this offering is for psycho-education only, and not a replacement for therapy, mental health care, or medication.
Consent and Hold Harmless Agreement. I am of legal age and in consideration of my acceptance as a participant in this group, class, training, seminar or any other ReNewNM production, I for myself, my heirs, executors, administrators and assignees, do hereby release and discharge the instructor, the host venue, ReNewNM Therapy LLC, and any of their employees and other participants from all claims of damages, copyright, demands or actions whatsoever in any manner arising from my participation. By attending, I signify my agreement with these statements.
I have received a copy of the HIPAA disclosure (click here to read full HIPAA Disclosure).
In addition, I agree to the following statement: I am ready to be an active participant in my experience, and do all required homework.

Mom/Birthing Person’s Agreement

Type your name to indicate agreement to each of the six statements above. Typing your name is your electronic signature and agreement.

Partner’s Agreement

Type your name to indicate agreement to each of the six statements above. Typing your name is your electronic signature and agreement.

Anything else you’d like us to know?

Bringing Baby Home!