Apply for care – Prince George

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 *

Address *

City *

Postal Code *

Phone *

Email *

Occupation *

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

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

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. *

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 not, 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 partnerNo, I don't have a partnerIt's Complicated

Will your partner be involved? *YesNoHe doesn't know about the pregnancyUnsure at this timeI 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. *

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

• Yes, I understand

Submit