Me & My Baby Parenting Program – Tabula Rasa Psychology

Me & My Baby Parenting Six Week Program

This Class is perfect for a young or teen birthing person. Attendees can be pregnant or in the postpartum period.

February 27 – April 12, 2023 (skip spring break)

Online 6 week series with classes on Monday & Wednesday Evenings 6:00 – 7:00

Cost: We can bill your insurance – or – pay cash: $25 each class.

Certificate of completion presented to those who attend all classes.

Week 1
Community Resources (Women, Infant, and Children – WIC), Food Stamps, Medicaid, Daycare, Early Childhood Intervention (ECI), Nurse Partnership, Pediatrician, Healthy Mom/Healthy Baby, Support System, Doctor Visits, Immunizations, and Self-Care.
Week 2
Mental Health: Perinatal Mood & Anxiety Disorder – PMAD, Stress, Postpartum Blues vs. Depression, and Perinatal Psychosis.
Week 3
ABCs of Safe Sleep Co-Sleeping/Crib Sleeping, Bed Sharing, Swaddling, Tummy Time, Back Sleeping, Water, and Car Safety.
Week 4
Shaken Baby Syndrome, Sudden Infant Death Syndrome (SUDS), Prevention of Child Abuse and Neglect, Baby Moses Law.
Week 5
Child Development – Bowel Movements, Feeding, Burping, Baby Rashes, Cradle Cap, Bald Patches, Differential Shaped Heads, Soft Spots, Flat Spots, Crossed Eyes, Groaning Noises, Clothing Your Child, Sneezing, Milestones, Jerky Movements, Swollen Genitals, Blood in Diaper/Stool, Newborn Crying, Feeding and Diaper Changing, Baby Weight (Down/Up), Baths, Avoiding Large Crowds.
Week 6
Drugs, Alcohol, Smoking, Recap, and Questions.

Register for the program below!

First Name *

Last Name *

Middle Name

Gender Identity *

Street Address *

City *

State *

Zip *

Primary Phone Number *

Phone Number Type

Secondary Phone Number

Phone Number Type

E-Mail *

Date of Birth (MM/DD/YYYY) *

Marital Status

Emergency Contact

Contact Full Name

Phone Number

Relationship

Work

Employer

Job Title

Phone Number

Address

Zip Code

Insurance

Will you be paying by insurance? If yes, insurance information below is required or we will consider this cash pay. *

Insurance Company

Member/Policy Number

Group Number

Insurance Contact Number

*Please upload a photo of your insurance card and ID once granted access to the portal. This occurs when you are removed from the waitlist and provided a new patient appointment.

Information of Policy Holder or Financially Responsible Party (If Not Self)

Relationship to Patient

Policy Holder or Financially Responsible Party’s Full Name

Policy holder’s Date of Birth (MM/DD/YYYY)

Phone Number

Address / Zip (If Different from Patient)

Referral Information

How were you referred to us? *

Please be advised, this course is 100% online.

Is there anything you want us to know?

Office Policy Agreement

All sessions of the course must be attended in order to obtain the certificate of completion.

Should you become a patient of the practice in the future be advised of the following policies.

All cancellations/reschedules made at least 24 hours in advance of the scheduled appointment are not charged. If you late cancel or no show your new patient appointment, you will not be given another appointment option with this office. After your new patient appointment, late cancellations/reschedules and no-show appointments will be charged according to the current fee. Insurance will not reimburse you for this charge. For repeated no-shows or late cancel/reschedules, all future appointments will be canceled until you are able to attend scheduled appointments without missing them.

This practice requires a credit/debit card on file to secure appointments. You will be asked to submit this number through the patient portal, which is a secure file. This card will be used primarily for copayment/co-insurance/session fees and for no-shows and late cancellations. By agreeing to the terms and providing your credit/debit card, you are acknowledging that you are aware that your card will be charged according to the office policies. After agreeing to the terms and providing your credit/debit card, if you contact your bank or card company to deny this charge, resulting in a “chargeback,” any additional fees associated with that chargeback will be added to the original missed appointment fee. Thank you for your cooperation with this necessary policy.

I agree to these office policies and give permission to charge the card on file accordingly. *

Me & My Baby Parenting Six Week Program

This Class is perfect for a young or teen birthing person. Attendees can be pregnant or in the postpartum period.

February 27 – April 12, 2023 (skip spring break)

Online 6 week series with classes on Monday & Wednesday Evenings 6:00 – 7:00

Cost: We can bill your insurance – or – pay cash: $25 each class.

Certificate of completion presented to those who attend all classes.

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Register for the program below!

Emergency Contact

Work

Insurance

Information of Policy Holder or Financially Responsible Party (If Not Self)

Referral Information

Office Policy Agreement

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