Mindful Parents Connection Course Client Questionnaire

This form is to help me to get to know you and your family a bit better prior to starting the Mindful Parents Connection Course. It helps me to tailor our sessions to the parents in the group. There is no pressure to share anything you don’t want to, and all questions are optional except for your contact information.

All responses and information shared during our discussions are strictly confidential and all paperwork including this completed form are kept in accordance with GDPR regulations. Please complete and return this form a minimum of 24 hours before your first session to enable me time to prepare for our time together. If you experience any issues with this form, please email me at info@themilkhub.co.uk

Your name *

First

Last

What are you preferred pronouns for yourself and your family?

Your email address *

Your telephone number *

Your address

What is the name of your baby/babies?

For attendees with more than one child, this question relates to the baby or babies you are currently feeding (feeding meaning breastfeeding, pumping or combi-feeding). This might include tandem feeding older children, or feeding multiples (twins, triplets etc).

How many weeks old is baby/babies now?

Please include the ages of all the children you are currently feeding.

What is the name of your partner/supporter?

First

Last

What is your relationship to your named partner/supporter?

E.g. husband, wife, partner, friend, parent, etc.

If you/your partner have older children or step children, please let me know their names and ages.

Can you tell me a little about your birth experience?

This might include how your baby/babies arrived (e.g. induction, assisted birth, c-section etc), and if there were any medical concerns for you or baby. You can also include details of how you feel about the birth if you would like to share them.

How are you feeding baby at the moment? E.g. exclusively breastfeeding, pumping, combiner's-feeding etc. Can you tell me a little about your feeding journey so far?

Are there any specific anxieties, concerns for feelings you are expecting at the moment which may be helpful to explore mindfulness techniques?

Are there any specific anxieties, concerns or feelings you are experiencing at the moment that may be helpful to explore with mindfulness techniques?

Is there anything else you'd like to share with me?

Thank you for taking the time to complete the questionnaire, I know it is quite long! The more detail I have prior to the session means the more time we can focus on tools and techniques for you.

By completing and submitting this questionnaire you are giving permission for The Milk Hub to collect and process the above information including any personal information as defined under GDPR regulations, and in line with both our legitimate interests. All information you supply is held in the strictest confidence and not shared with any third parties without your consent. Completing and submitting this questionnaire also acknowledges that you accept the Privacy Notice and Terms and Conditions listed on the website The Milk Hub.

I agree

Mindful Parents Connection Course Client Questionnaire

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