Welcome to your Mama, How Are You Really Feeling?.Thinking about the past 2 weeks, select the response that best describes how you've
been feeling.

Name

Phone

Which best describes you right now?

If pregnant, how many weeks?

If you recently had a baby, how old is your baby?

If you experienced a pregnancy or infant loss, when did it occur?

I have felt sad, empty, tearful, emotionally numb, or overwhelmed.

Not at all

Sometimes

Often

Almost every day

I have had difficulty enjoying things I normally enjoy.

Not at all

Sometimes

Often

Almost every day

I have felt worried, nervous, fearful, or unable to relax.

Not at all

Sometimes

Often

Almost every day

I frequently worry that something bad may happen to me, my pregnancy, or my baby.

Not at all

Sometimes

Often

Almost every day

My mind races or is difficult to quiet, even when I have an opportunity to rest.

Not at all

Sometimes

Often

Almost every day

I experience unwanted, upsetting, or frightening thoughts or images that are difficult to get out of my mind.

Not at all

Sometimes

Often

Almost every day

I repeatedly check things, seek reassurance, or repeat certain behaviors because I need to feel that everything is okay.

Not at all

Sometimes

Often

Almost every day

I avoid certain activities or situations because I'm afraid something bad could happen.

Not at all

Sometimes

Often

Almost every day

I have felt more irritated, frustrated, or angry than usual.

Not at all

Sometimes

Often

Almost every day

My anger sometimes feels sudden, intense, or difficult to control.

Not at all

Sometimes

Often

Almost every day

Crying, noise, being touched, interruptions, or everyday demands sometimes feel like too much.

Not at all

Sometimes

Often

Almost every day

I have reacted more strongly than I wanted to and later felt guilty, embarrassed, or upset about my reaction.

Not at all

Sometimes

Often

Almost every day

I have felt disconnected from myself, my pregnancy, or my baby

Not at all

Sometimes

Often

Almost every day

I have felt guilty, inadequate, or questioned whether I'm doing a good enough job

Not at all

Sometimes

Often

Almost every day

Worry, racing thoughts, strong emotions, or upsetting memories make it difficult for me to sleep even when I have an opportunity to rest.

Not at all

Sometimes

Often

Almost every day

If You've Experienced Pregnancy or Infant Loss

Complete this section if you have experienced miscarriage, pregnancy loss, stillbirth, or
the death of a baby. Otherwise, you may skip this section.

Thoughts or memories about my loss can feel overwhelming

Not at all

Sometimes

Often

Almost every day

I experience strong sadness, longing, anger, guilt, or other difficult emotions related to my loss.

Not at all

Sometimes

Often

Almost every day

I sometimes blame myself or wonder whether I could have done something differently

Not at all

Sometimes

Often

Almost every day

Pregnancy announcements, babies, certain dates, places, people, or other reminders of my loss can be difficult for me.

Not at all

Sometimes

Often

Almost every day

I have felt alone, isolated, or misunderstood in my grief.

Not at all

Sometimes

Often

Almost every day

My loss has affected my relationships, sleep, work, daily activities, or ability to care for myself.

Not at all

Sometimes

Often

Almost every day

I would like an opportunity to talk with someone about my pregnancy or infant loss

Not at all

Sometimes

Often

Almost every day

Your Daily Life & Support

The way I have been feeling is making it harder to manage my everyday responsibilities

Not at all

Sometimes

Often

Almost every day

I feel like I need more emotional or practical support than I currently have.

Not at all

Sometimes

Often

Almost every day

I feel supported by the people closest to me.

Not at all

Sometimes

Often

Almost every day

Your Safety Matters

During the past 2 weeks, have you had thoughts that you would be better off dead or thoughts of hurting yourself?

Not at all

Sometimes

Often

Almost every day

Have you had thoughts about harming your baby or another person?

Not at all

Sometimes

Often

Almost every day

Have you recently felt extremely confused, disconnected from reality, or experienced things that other people do not seem to see or hear?

Not at all

Sometimes

Often

Almost every day

Do you currently feel unsafe in your home or in a relationship?

Not at all

Sometimes

Often

Almost every day

What Would Feel Helpful Right Now?

Check all that apply.

I would like someone to talk to about how I've been feeling.

I'm struggling with worry, fear, or racing thoughts.

I'm experiencing unwanted or upsetting thoughts.

I'm struggling with repeated checking or behaviors that are difficult to stop

I've been feeling unusually angry, irritable, or overwhelmed

I'm grieving a pregnancy or infant loss

I'm having difficulty adjusting to pregnancy or motherhood.

I'm having difficulty feeling connected to my baby.

I'm struggling with sleep.

I'm experiencing relationship or family stress.

I have questions about medication.

I need help finding practical or community resources

I'm not sure what I need — I just know I don't feel like myself.

I'm doing okay right now, but I would still like to learn about available support.

I Would Like a FREE 15-Minute Consultation

Yes — please contact me

Maybe — I'd like more information

Not right now

Mama, How Are You Really Feeling?

If You've Experienced Pregnancy or Infant Loss

Complete this section if you have experienced miscarriage, pregnancy loss, stillbirth, or
the death of a baby. Otherwise, you may skip this section.

Your Daily Life & Support

Your Safety Matters

Quick Links

Working Hours

Location

Quantum Mental Health Wellness Center

If You've Experienced Pregnancy or Infant LossComplete this section if you have experienced miscarriage, pregnancy loss, stillbirth, orthe death of a baby. Otherwise, you may skip this section.

Your Daily Life & Support

Your Safety Matters

Quick Links

Working Hours

Location

Quantum Mental Health Wellness Center

If You've Experienced Pregnancy or Infant Loss

Complete this section if you have experienced miscarriage, pregnancy loss, stillbirth, or
the death of a baby. Otherwise, you may skip this section.