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New Mom Empowerment Experience (Application)
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Email
*
Your email
Name
*
Your answer
Age
*
Your answer
Martial Status
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Single
Married
Divorced
Widowed
Other:
Phone #
*
Your answer
Current Occupation (and the # of years)
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Your answer
Motherhood Status
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Expecting your first child (in first or second trimester)
New mom (child is under 3 years old)
New mom (child is age 4 or 5 years old)
Seasoned mom (with grandchildren under age 5 years old)
Number of Children (include their gender & age)
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Your answer
Reason you’re seeking to be part of this group at this time
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Your answer
What are your Top 3 worries (or concerns) about being a mom to your child/children?
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Your answer
What source(s) of support do you have in your life as you enter this next stage of motherhood?
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Your answer
What is one positive quality about you?
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Your answer
What is one quality about you that you need to improve upon?
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Your answer
What is your level of openness to change? [On a scale of 0 to 10; 0 = not open; 5 = neutral (neither open nor not open); 10 = very open]
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Not Open
0
1
2
3
4
5
6
7
8
9
10
Very Open
What do you believe about parenting children?
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Your answer
What do you believe about motherhood?
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Your answer
How do you see the world?
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Your answer
What kind of investment are you willing make in yourself and/or your mother-daughter (or mother-child) relationship at this time?
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$3,000 - $4,999
$5,000 - $9,999
$10,000+
Not able to invest at this time
What else would you like me to know?
*
Your answer
A copy of your responses will be emailed to the address you provided.
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