Beyond the Bump – Client Care Application

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.

Name *

First

Last

Age *

Primary Language *

What Hope for Women site do you prefer to be connected with? *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Occupation *

Layout

Phone *

Email *

Is it safe to contact you by phone, email or text? *

How would you prefer to be contacted by your mentor? *

How did you hear about us? *

Google
Doctor/Midwife
Social or Support Worker
Friend/Family
Church
Community Agency
Driving by
Hope for Women Client
Social Media
Other

What is your due date or c-section date? *

Please list all people living in your household and provide a brief explanation of your relationship to them.

Press the + button to add additional household members

Name *

Relationship to this person *

Please share with us who is on your support team. This could be your partner, family, friends, social worker, your church, or your neighbours. *

Are you receiving support from any other agencies? (check all that apply)

Care for Women
Doula
Public Health Nurse
Social Worker
Lactation Consultant
Other

Please Specify *

Please let us know your concerns and why you believe our program will be helpful for you. *

Do you have any food allergies? *

Please list your food allergies *

Do you have any pets? *

What kind of pets do you have? *

Do you have any smokers in your home? *

Total combined income for all contributing adults in the home. *

Do you have a partner? *

Will your partner be involved? *

We know that some relationships are thriving while others can be quite messy. Please describe your relationship with your partner. *

Is there anything in particular that you would like your mentor to know beforehand? For example, previous birth experiences, worries/fears, triggers/traumas. *

I understand that my mentor and support worker may collaborate in order to provide my baby and I with optimal care. *