Perinatal Group Registration Form

Thank you for your interest in our 4-week Perinatal Support Group at The Well Woman.
To register, please complete the form below. This group is open to individuals who are between 20 and 35 weeks pregnant and 18 years or older. A brief screening appointment is required to ensure the group is a good fit for your needs. Once you submit the form, we’ll contact you within 1 business day to schedule your screening.

Personal Information

Full Name

Date of Birth

Phone Number *

Email Address *

Home Address

Demographic Information

Race/Ethnicity

Black/African American

White

Hispanic/Latino

Asian

Native American

Multiracial

Other

Emergency Contact Name & Relationship

Emergency Contact Phone Number

Payment & Insurance Information

How do you plan to pay?

Self-Pay ($45/session or $165 for full 4 weeks)

Insurance (subject to authorization)

Insurance Provider:

Member ID:

Group Number:

Subscriber Name (if different from participant):

Subscriber Date of Birth:

Availability & Commitment

Are you available for the full 4-week support group (Thursdays, 7 PM – 8 PM)?

YES

Do you understand that missing multiple sessions may impact your progress and may result in dismissal from the group?

YES

Screening Appointment

A screening appointment is required before starting the group.

Self-pay rates: The initial screening appointment (30–45 minutes) is $75. The individual postpartum booster session (45 minutes) is $110.
If using insurance, your plan may cover the screening and postpartum appointments.

Consent & Agreement

Participants will be given consent forms to complete prior to initiating services.

Signature:

Clear

Date: