Maternal Vitality Study- Interest Form for Interested Women/Mothers

Interested in signing up for our Maternal Vitality Study? Please complete this interest form below.

- Step 1 of 6

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

If you live in an apartment, or a multi-family home, please put your apartment number or UP/Down.

Age

Date of Birth *

Mom's Date of Birth

Race

example: Black

Ethnicity

examples: African American, African Caribbean, Latino

Are you currently pregnant, or were you recently pregnant within the last 12 months regardless of how your pregnancy ended? (This includes birth, abortion, miscarriage, etc.) *

Would you like to share more about your birth/delivery story? For example, did you have a vaginal birth or miscarriage? We can also hold this question for later.

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Have you ever been diagnosed with maternal psychosis by a medical professional? *

Yes
No
Unsure

People with Postpartum Psychosis (PPP) have a much higher risk of harming themselves, dying by suicide or harming their children. Because of this, PPP is a mental health emergency. If you have the symptoms of PPP or are near someone who shows signs of it, it’s important to seek immediate help. If you believe someone is a danger to themselves or others, you should immediately dial 9-1-1 (or your local emergency services number at 2-1-1). If you are currently receiving therapy services, we encourage you to consult further with your counselor for questions or concerns. If you are not currently receiving therapy services we invite you to join our maternal depression services that serve moms during pregnancy, and any time after pregnancy. We can connect you to this program if you call or email our offices. If you want to reach out on your own for OhioGuidestone services, please contact our OhioGuidestone intake at 440-260-8300 or sign up for services on our website https://ohioguidestone.org/request-services/ . For even more services outside of OGS please visit www.namigreatercleveland.org.

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Have you ever been diagnosed with a major mental health condition such as schizophrenia or bipolar disorder by a medical professional? *

Yes
No
Unsure

Schizophrenia refers to a condition and to a spectrum of disorders that all involve a disconnection from reality, including hallucinations and delusions. It affects a person’s ability to recognize the symptoms they have of this condition. Bipolar disorder is a chronic mood disorder that causes intense shifts in mood, energy levels, and behavior. Manic and hypomanic episodes are the main sign of the condition, and most people with bipolar disorder also have depressive episodes. We can connect you to this program if you call or email our offices. If you want to reach out on your own for OhioGuidestone services, please contact our OhioGuidestone intake at 440-260-8300 or sign up for services on our website https://ohioguidestone.org/request-services/ . If you are currently receiving therapy services, we encourage you to consult further with your counselor for questions or concerns. For even more services outside of OGS, call 2-1-1 or visit www.namigreatercleveland.org.

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Have you ever been diagnosed with a substance use disorder by a medical professional? *

Yes
No
Unsure

Substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home. We can connect you to this program if you call or email our offices. If you want to reach out on your own for OhioGuidestone services, please contact our OhioGuidestone intake at 440-260-8300 or sign up for services on our website https://ohioguidestone.org/request-services/ . If you are currently receiving therapy services, we encourage you to consult further with your counselor for questions or concerns. For even more services outside of OGS, call 2-1-1 or visit www.namigreatercleveland.org.

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Are you currently receiving therapy services? *

We encourage you to consult with your counselor about whether your interest in our study would disrupt your current therapeutic services. For further questions or concerns regarding maternal depression, we want to invite you to join our maternal depression services that serve moms during pregnancy, and any time after pregnancy. We can connect you to this program if you call or email our offices. If you want to reach out on your own for OhioGuidestone services, please contact our OhioGuidestone intake at 440-260-8300 or sign up for services on our website https://ohioguidestone.org/request-services/ . For even more services outside of OGS, call 2-1-1 or visit www.namigreatercleveland.org.

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This section asks questions about your mood or feelings. Please think about the past 2 weeks and answer each question.

Over the last 2 weeks, how often have you been bothered by the following problems?

Little interest or pleasure in doing things *

Not at all (0)
Several Days (1)
More than half the days (2)
Nearly every day (3)

Feeling down, depressed, or hopeless *

Not at all (0)
Several Days (1)
More than half the days (2)
Nearly every day (3)

This section asks questions about your mood or feelings. Please think about the past 2 weeks and answer each question.

Over the last 2 weeks, how often have you been bothered by the following problems?

Feeling nervous, anxious, or on edge *

Not at all (0)
Several Days (1)
More than half the days (2)
Nearly every day (3)

Not being able to stop or control worrying *

Not at all (0)
Several Days (1)
More than half the days (2)
Nearly every day (3)

Last Section

How did you learn about this project? *

Help Me Grow
Neighborhood Leadership Institute (NLI)
OhioGuidestone
A Community Healthcare Site (e.g. Birthing Beautiful Communities, Village of Healing)
Centering Pregnancy Group
Joyful Together -or- Father's Feelings
Email
Facebook or Instagram
Other

Thank You!

Thank you for completing the eligibility form for our Maternal Vitality Study at OhioGuidestone. If you have any questions, please email or call us. We will follow-up with you for next steps.

Save and Resume Later

Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

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Email *