Community Engagement

Motherhood Circle Intake Form

Welcome to our Motherhood Circle! We’re so glad you’re here. This form helps us get to know you better and ensure that we can provide support that meets your unique needs. All responses are confidential.

First Name *

Last Name *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Day Phone

Email Address *

Your Motherhood Journey

How far along are you in your motherhood journey?

Expecting
New Mom (0-6 months)
Experienced Mom (6+ months)
Struggling with Infertility
Other

Other

How many children do you have?

1
2
3+
Other

Other

Your Support Needs

What topics would you like to explore in the Motherhood Circle?

Breastfeeding Basics (Latching, Positioning, Milk Supply)
Nutrition and Self-Care During and After Pregnancy
Mental Health & Postpartum Wellness (Postpartum Depression, Anxiety)
Parenting Techniques and Child Development
Family Planning & Child Spacing
Relationship Support (Partner Communication, Balancing Roles)
Labor Preparation and Prenatal Care
Immunizations and Vaccine Safety
Injury Prevention (SIDS, Car Seat Safety)
Trauma-Informed Care and Self-Advocacy
Infertility Support and Resources
Other

(Check all that apply)

Other

What do you hope to gain from joining the circle?

Knowledge and Guidance
Emotional Support
Community and Connection
Confidence in My Motherhood Journey
Other

(Check all that apply)

Other

Challenges & Support

What are some challenges you’re currently facing in your motherhood journey?

(Optional but helpful)

How can we best support you during this time?

Peer support and shared experiences
Expert advice and resources
Emotional check-ins
Practical tips for managing daily life
Other

Other

Additional Information

Is there anything else you’d like us to know to make your experience more meaningful?

Motherhood Circle Schedule calander

We Believe We Mother Better When We Mother Together!

Empowering Women Through Equitable Support, Building Lifelong Friendships, and Improving Health Literacy to Strengthen Our Families and Communities.

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(612) 987-4505

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info@inspirechangeclinic.org

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inspirechangeclinic.org

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