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Pregnant Parents Materials Assistance Form
I am a:
New Client
Returning Client
Diaper Dash Event Date
First Name
Last Name
Date of Birth
Zip Code
Phone Number
Email
Are you a U.S. Citizen
Yes
No
Sex
Male
Female
Marital Status
Married
Single
Have you received prenatal care from a physician
Yes
No
What trimester did you receive care in?
First
Second
Third
How many weeks along are you?
Number of other children who are 1 day or older?
Highest education completed
Less than high school
Some high school
High school degree or GED
Some college
College degree
Some post-graduate
Post-graduate degree
Ethnicity
Black (non-Hispanic)
Hispanic
White (non-HIspanic)
Asian or Pacific-Islander
American Indian/Alaska Native
SPIRITUAL PREFERENCE
Among the many services we can provide you, some can help you with your spiritual health. For example, if you find comfort in prayer, someone here can pray with you, if you’d like. We offer spiritual services because they’re a part of our faith background. However, we will not offer to provide you spiritual services if you don’t want us to. All of the other services we provide are still here for you, even if you decide not to receive spiritual help. If you are open to receiving spiritual services, I will introduce you to another counselor here who will provide these services to you. And, if you prefer not to receive any services - spiritual or otherwise - from us, we will help you find another provider of your choice. Please check your preference below
No, thank you, but at this time I do not want you to offer me any spiritual services.
Yes, it is okay with me if you offer me spiritual help during my time here.
REQUEST FOR MATERIALS
Age/Sex of Child
Child Accessories (check all that apply)
Bottles
Wipes
Baby Wash/Lotion
Diaper Cream
Pacifiers
Sippy Cup
Diapers size (select all that apply)
0/Newborn
1
2
3
4
5
6
Other
Food (select all that apply)
Formula
Baby Food
Rice/Cereal/Oatmeal
If applicable, please specify formula kind
Breastfeeding
Similac Advance/ Blue Can
Similac Sensitive/ Orange Can,
Similar Pro-Advance/ Silver Can
Similac Pro-Sensitive
Similac 360 Total Care
Enfomil Neuro Pro
Enfomil Neuro Pro Sensitive
Enfomil Gentlease
Other Formula Not Listed
Adult Toiletries
Body Wash
Deodarant
Toothbrush/Toothpaste
Educational Handouts: What topics would you like more information on as a parent?
Birthing
Birthing options
Creating good sleep habits
Postpartum care
Postpartum depression
Breastfeeding
Infant/ child safety
Balancing my time
Being a single parent
Child development and health
Nutrition
New parent resources
Pregnancy/ parenting and COVID
Housing resources
Car seat safety
Obtaining my GED or college degree
Other: Topics not listed above
Notes
Send
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