Healthy Families
Please answer questions below and we will reach out to you! Thank you
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Mother’s Name
Mother’s date of birth
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DD
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Home Address
Phone number
Baby’s due date/ date of birth
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DD
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YYYY
Email Address
First child?
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Marital Status
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Do you receive Medicaid?
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Do you receive WIC?
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Do you receive disability?
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What is the highest level of education you completed?
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Are you concerned with your housing situation?
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Are you staying in a shelter?
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Are you temporarily staying with family or friends?
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Do you have a history or have current substance abuse?
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Do you have a history or have current depression?
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Do you have a history or have current psychiatric care?
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Do you agree to have a Healthy Families staff contact you to receive more information about the program
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How did you hear about us? If referring for self, say self. If referring for someone else, say what agency you are with! Thank you!
Anything else you would like for us to know!
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