Claudette Free Outreach

Step 1 of 4

25%

Name(Required)

First Middle Last

Address(Required)

Street Address City State

Postal Code/ZIP(Required)

Zip code

How long at this address?

Months

Birthday

Year

Month

Day

Email(Required)

Weeks Pregnant

Please enter a number from 1 to 41.

Due Date / Date Delivered

Year

Month

Day

Which of the following best describes you?(Required)

Asian or Pacific Islander

Black or African American

Hispanic or Latinx

Native American or Alaskan Native

White or Caucasian

Multiracial or Biracial

A race/ethnicity not listed here

Decline

Other

Primary Phone Number(Required)

Secondary Phone Number

Are you over 18? If you are under 18, please have your guardian update and sign at the bottom

Yes

Guardian of Participant's Full Legal Name

Relationship

Guardian's Email Address

Guardian's Phone Number

Referral Source (How did you hear about us?)(Required)

CB Outreach

Since we will be providing telehealth services, we have available free tablet and T-Mobile internet. Would you need a free tablet and free internet?

Yes

Medical Information

Medications or Supplements

Yes

List All Medications or Supplements

Medical Concerns

Alcohol Use

Food Insecurity

Gestational Diabetes

History or Current Anxiety

History or Current Depression

History or Current OCD

History or Current PTSD

History or Current Sexual Trauma

Housing Insecurity

Hypertension

Intimate Partner Violence

Partner Relationship Issues

Tested Positive for COVID-19

Transportation Insecurity

Vaginal Tearing

Others/None

Allergies

Any other Medical Concerns + Complications

Medical Treatments

Name of OB/GYN or Midwife

Classes you would like to take

Breastfeeding

Childbirth Education

Infant Care

Other

Planned Birth Location

Birth Center

Home

Hospital

Labor Preferences

Planned Cesarean

Vaginal

VBAC

Unsure

Things you would like to learn more

Birth Plan

Breast Pumps

Communication Plan

Comfort Measures

Cultural Expectations

Early Labor Communication

Expectations of Client

Expectations of Doula

Healthy Start

Infant Care (feeding)

Labor Pain Management

Labor Preparation

Postpartum Communication

Postpartum Preparations

Religious Expectations

WIC

Number of Live Births

Please enter a number from 0 to 10.

Number of Abortions (value 0 - 10+)

Please enter a number from 0 to 10.

Number of Miscarriages (value 0 - 10+)

Please enter a number from 0 to 10.

Number of Living Children (value 0 - 10+)

Please enter a number from 0 to 10.

Would you like us to make a referral to any of these resources?

Acupuncturist

Car Seat

Case Manager

Chiropractor

Healthy Start

Health Plan Rewards

Diaper Bank

Lactation Consultant

Massage Therapist

Mental Health Support

Pelvic Floor

Physical Therapy

WIC

Insurance

Insurance / Payor Information

Self Pay

Humana

Medicaid

Sunshine Health

Florida Blue

United Health Care

Others

Other Insurance/Payor

Yes, I am consenting.(Required)

I am consenting to be entered into the Mama Thrive Program, a part of the Severe Maternal Morbidity Telehealth Program (SMMT).

Yes, I authorize.(Required)

I authorize Agape Family Health and other Community Partner's to gather information, contact me by all available ways (Call, Email, Text, Mail, Telehealth, Notifications, etc.) and provide additional services during pregnancy and 3 months postpartum.

Yes, I understand.(Required)

I understand that all information gathered may be used to determine program eligibility. This authorization remains in effect until revoked in writing by me.

Participant's Full Legal Name(Required)

Signature(Required)

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