Let’s get to know youAll information will be treated confidentially Name * First Name Last Name Pronouns Pronouns Email * Phone (###) ### #### Which of the following stages are you in? check all that apply Pre-conception / pre-adoption 1st trimester 2nd trimester 3rd trimester Immediate postpartum - up to 1 year since welcoming your child Extended postpartum - over 1 year since welcoming your child Birthing parent Non-birthing parent Adoption When is your baby due / When was your last baby born? MM DD YYYY Do you have older children? If yes, what year(s) were they born? What is your current title and role? How long have you been in this role and with this company? Are you eligible for any type of parental leave? If yes, for how long? Paid or unpaid? Short-term disability, PTO, state/city/union benefits, company-sponsored pay, etc. Does your company provide any support to working parents? check all that apply Employee Assistance Program (EAP) Employee Resource Groups (ERG) Backup childcare services/reimbursement Food delivery Lactation support/breast milk services Financial planning/legal support (wills, estate planning, etc.) Infertility/miscarriage/infant loss support Other Share your LinkedIn, so I can learn more about your professional background http:// What worries you most about becoming a working parent? Describe anything else that would be helpful for me to know before we meet: Thank you for completing this form. Next steps: We will schedule a call to discuss your goals for this program. Look out for an email coming your way soon.If you have any questions, reach out to HeikeMitchell@gmail.com
