Age *
Primary Language *
Address *
City *
Postal Code *
Phone *
Email *
Occupation *
Is it safe to contact you by phone, email or text? * Yes No
How would you prefer to be contacted by your mentor? * Phone Text Email
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. *
Please share with us who is on your support team. This could be your partner, family, friends, social worker, your church, or your neighbours. *
Please let us know your concerns and why you believe our program will be helpful for you. *
Do you have any food allergies? If yes, list below. If no, write N/A *
Do you have any pets? If yes, what kind? *
Do you have any smokers in your home? *
Total combined income for all contributing 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+
Do you have a partner? * Yes, I have a partner No, I don't have a partner It's Complicated
Will your partner be involved? * Yes No He doesn't know about the pregnancy Unsure at this time 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. *
Is there anything in particular that you would like your mentor to know beforehand? For example, previous birth experiences, worries/fears, triggers/traumas. *