ABOUT
APPLY FOR CARE
MENTEE FEEDBACK FORM
VOLUNTEER
MENTOR PORTAL
DONATE
TESTIMONIALS
RESOURCES
APPLY FOR CARE
Please note that some of the questions below may be sensitive in nature. We ask these questions so that our team can better understand how we can best serve you and your family. All information is kept strictly confidential.
*
Indicates required field
NAME
*
First
Last
AGE
*
PRIMARY LANGUAGE
*
ADDRESS
*
Line 1
Line 2
City
State
Zip Code
Country
PHONE NUMBER
*
EMAIL ADDRESS
*
IS IT OKAY/SAFE FOR US TO CALL, TEXT OR EMAIL YOU?
*
YES
NO
HOW WOULD YOU PREFER TO BE CONTACTED BY YOUR MENTOR?
*
PHONE
TEXT
HOW DID YOU HEAR ABOUT US?
*
GOOGLE
DOCTOR/MIDWIFE
SOCIAL/SUPPORT WORKER
FRIEND/FAMILY
CHURCH
COMMUNITY AGENCY
DRIVING BY (ROAD SIGN)
HOPE FOR WOMEN CLIENT
OTHER
WHAT IS YOUR DUE DATE?
*
ARE YOU ATTENDING PRENATAL CLASSES
*
YES
NO
DO YOU HAVE A DOULA FOR YOUR BIRTH
*
YES
NO
PLEASE LIST AGE AND SEX OF ALL CHILDREN IN YOUR HOUSEHOLD.
*
DO YOU HAVE ANY OTHER CHILDREN? EG. IN CARE, PLACED FOR ADOPTION, WITH FAMILY, ETC.
*
HOW MANY PEOPLE ARE LIVING IN YOUR HOUSEHOLD? BRIEFLY EXPLAIN YOUR RELATIONSHIP WITH EACH PERSON LISTED.
*
WHAT IS YOUR LIVING SITUATION? BRIEFLY EXPLAIN THE PHYSICAL CONDITION OF YOUR HOME. EG. CLEAN, HOARDING, MESSY, INFESTATION, ETC
*
DO YOU HAVE ANY FOOD ALLERGIES? IF YES, PLEASE LIST BELOW.
*
DO YOU HAVE ANY PETS IN YOUR HOME? IF YES, WHAT KIND?
*
ARE THERE ANY SMOKERS IN YOUR HOME?
*
OCCUPATION
*
TOTAL COMBINED INCOME (FOR ALL WORKING ADULTS IN THE HOME)
*
$0 - 14 000
$14 000 - 20 000
$20 000 - 25 000
$25 000 - 35 000
$35 000 - 50 000
$50 000 - 75 000
$75 000 +
Please note that your last 3 months bank statements will be required for review.
DO YOU HAVE A PARTNER?
*
YES
NO
IT'S COMPLICATED
WILL YOUR PARTNER BE INVOLVED
*
YES
NO
UNSURE AT THIS TIME
HOW DO YOU FEEL WE CAN BEST SUPPORT YOU? (PLEASE BE SPECIFIC)
*
IS THERE ANYTHING IN PARTICULAR THAT YOU WOULD LIKE YOUR MENTOR TO KNOW BEFORE HAND? EG. PREVIOUS BIRTH STORIES, WORRIES/FEARS, PAST TRAUMAS/TRIGGERS
*
I UNDERSTAND THAT MY MENTOR AND SUPPORT WORKER MAY COLLABORATE IN ORDER TO PROVIDE MY BABY AND I WITH OPTIMAL CARE.
*
I AGREE
Submit
ABOUT
APPLY FOR CARE
MENTEE FEEDBACK FORM
VOLUNTEER
MENTOR PORTAL
DONATE
TESTIMONIALS
RESOURCES
