1st Session, Perinatal Counselling: Restoring Wholeness in Early Parenthood

Tania Fragoso

Perinatal Counsellor & Coach

90 Minutes

Personal Information

First Name

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Last Name

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Phone Number

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Time Zone

Additional Information

Basic Information

Full Name

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Date of Birth:

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Location: (Address, Postcode, and City)

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Contact Details: (Phone and Email)

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Current Relationship Status:

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Occupation/Education:

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Family & History

Do you have children?

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Children’s ages and any specifics: (e.g., birth stories, neurodivergence, or health needs)

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Personal Background: (Briefly describe your character or keywords that feel like "you")

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Interests: What are your hobbies or ways you find joy/rest?

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Wellbeing & Support History

Overall Health: How would you describe your current physical and mental well-being?

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Usage: Do you use any medicines, drugs, or alcohol? (If so, how often?)

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Previous Support: Have you worked with a coach, psychologist, or therapist before?

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Past Topics: If yes, was it for the same reason you are seeking support now, or something different?

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Our Work Together

Current Goals: What is the primary question or goal you want to explore?

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Desired Outcome: What does "success" or feeling supported look like to you at the end of our sessions?

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Expectations: What do you expect or need from me as your coach/counsellor?

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Additional Space: Is there anything else you’d like me to know before we begin?

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Neuro-Affirming & Communication Preferences

Sensory Needs: Do you have any sensory preferences for our sessions (e.g., preference for camera on/off, specific lighting, or being able to move/fidget while we talk)?

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Communication Style: How do you process information best? (e.g., "I need time to think before answering," "I prefer written summaries after calls," or "I like direct, clear feedback.")

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Executive Function Support: Is there anything I can do to make our sessions more accessible for you (e.g., sending a reminder 15 minutes before, or keeping a shared digital list of our "next steps")?

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Energy Levels: Are there specific times of day when your "brain fog" or fatigue (if applicable) is most manageable?

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Trigger Awareness: Is there anything specific regarding birth language or certain topics that you find particularly overwhelming or would like me to approach with extra care?

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Emergency & Crisis Support

Emergency Contact Name:

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Relationship to you:

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Emergency Contact Telephone:

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Your Local Emergency Services: (e.g., 112 in Spain/Europe, 999 in the UK)

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GP or Local Medical Practice Name & Number:

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Safety Agreement: "In the event of a mental health crisis or if I become concerned for your immediate safety during our online session, I have your permission to contact the individual listed above or local emergency services. Do you agree to this?

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