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ABOUT ME:
First Name:*
Last Name:*
Preferred Pronouns:
Race/Ethnicity*
POEM Rise seeks to direct peer support and referral services to priority populations-namely, Black and African American mothers and birthing persons.

CONTACT INFORMATION:
E-mail Address:*
Phone Number: ok to leave message
ZIP Code:*

ABOUT MY NEEDS:
I heard about POEM from:*  

I would like to talk to POEM about the following concern(s):*
Maternal depression or anxiety
Postpartum adjustment/blues
Perinatal OCD
Perinatal Bipolar Disorder or Psychosis
Perinatal Loss
Perinatal specialist network
Support Group
Mentoring Program
Connecting a family member/loved one
Not listed (please describe below)
 
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If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat 988lifeline.org

The National Maternal Mental Health Hotline at 1-833-TLC-MAMA (1-833-852-6262) is available 24/7 for non-crisis talk support.

By clicking the "Submit Application >" button below, I understand that the information I submit will be used by POEM to match me with the most appropriate service(s) based on my problem or other factors. Certain information may be provided to these programs so that they have basic information about my situation.


Please click the button only ONCE. It will take a few moments for the submission to complete.

PLEASE NOTE POEM Program 2024 Holiday Season Hours:

Beginning at noon on 11/27/2024 to 11/30/2024, the POEM Team will be away from the office, taking dedicated time and engaging in self-care during the holiday season. Please note that our support line will not be monitored during these specified dates and times. We will promptly attend to all inquiries upon our return during the week of 12/02/2024. Additionally, we will be away from the office starting at noon on 12/24/2024 to 12/26/2024, and again from 12/31/2024 to 01/02/2025, as our team continues to prioritize personal well-being. The support line will not be monitored on the mentioned dates, and there will be no POEM support group meetings from 12/21/2024 to 01/03/2025. We value your understanding as our team takes this time for rest and rejuvenation. In the meantime, we encourage you to explore alternative resources, such as Postpartum Support International’s support offerings and the national maternal mental health hotline, available at 1-833-TLC-MAMA (1-833-852-6262). If you are in crisis, please call or text 988.