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?
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YES
NO
Occupation
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Total combined income of all contributing adults in the home.
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$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.
How did you hear about us?
*
GOOGLE
DOCTOR or MIDWIFE
SOCIAL or SUPPORT WORKER
FRIEND or FAMILY
CHURCH
COMMUNITY AGENCY
DRIVING BY (ROAD SIGN)
HOPE FOR WOMEN CLIENT
SOCIAL MEDIA
OTHER
What is your due date or c-section date?
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Please list all people living in your household and provide a brief explanation of your relationship to them.
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Please share with us who is on your support team. This can include your partner, family, friends, social worker, your church, or your neighbour.
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Please let us know your concerns and why you believe our program will be helpful to you.
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WHAT IS YOUR LIVING SITUATION? BRIEFLY EXPLAIN THE PHYSICAL CONDITION OF YOUR HOME. EG. CLEAN, HOARDING, MESSY, INFESTATION, ETC.
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Do you have any food allergies? If yes, please list below. If no, write N/A.
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Do you have pets in your home? If yes, please list what kind.
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Are there any smokers in your home?
*
Do you have a partner?
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Yes
No
It's complicated
I don't have a partner
Will your partner be involved?
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Yes
No
Unsure at this time
He doesn't know about the pregnancy
I don't have a partner
We know that some relationships are thriving while others can be quite messy. Please describe your relationship with your partner.
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Is there anything more than you would like your mentor to know beforehand? Eg. previous birth experiences, worries or fears, triggers or traumas.
*
I understand that my mentor and support worker may collaborate in order to provide my baby and I with optimal care.
*
I AGREE
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ABOUT
APPLY FOR CARE
MENTEE FEEDBACK FORM
VOLUNTEER
MENTOR PORTAL
DONATE
TESTIMONIALS
RESOURCES
