Name *

First Name

Last Name

Phone

(###)

###

####

Check all that applies

Birth Trauma

Partner birth trauma

Panic/anxiety attacks

Conception/Fertility

Feelings of Guilt, Anger, Shame or resentment.

Chronically worried

Provider abuse

Stallel labor (prodomal labor)

Fear of induction

Fear of pitocin

Fear of c-section

Fear of pain

Other phobias

Relationship issues (with partner, family or friends)

Mother-baby bonding issues

Unbearable nausea and vomiting

Obsessive Compulsive Disorder

Insomnia

Secondary Traumatic Stress (affected by other people's birth experiences)

Fear of miscarriage

Loss or grief after miscarriage

Gender violence

Feeling Isolated/lonely

Breastfeeding issues

White Coat Syndrome

Stress over adjusting to parenthood/life changes

Feeling overwhelmed

Pregnancy Depression

Postpartum Depression

Something else (please describe in the message section).