The Village Innovating Perinatal Services Cohort Application

Funded Status

Name* This field is required.

First Name

Last Name

Email* This field is required.

example@example.com

Phone Number* This field is required.

Area Code

Phone Number

Mailing Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

How do you self identify?

Non-Hispanic White

Black or African American

Hispanic and Latino (of any race)

Asian

Native Americans and Alaska Natives

Native Hawaiians and Other Pacific Islanders

Are you applying as an individual or an organization?

Individual

Organization

What is the name of your organization?

Can you provide us with your website?

Select the primary population you serve.

Non-Hispanic White

Black or African American

Hispanic and Latino (of any race)

Asian

Native Americans and Alaska Natives

Native Hawaiians and Other Pacific Islanders

Select your corresponding HRSA region.* This field is required.

Select your primary geographic setting.

Urban

Suburban

Rural

How do you engage in the community?* This field is required.Select all that apply.

Doula

Lactation Support Provider

Maternal Mental Health Provider

Midwife

Medical Practitioner

Other

List any relevant credentials below. RN, CLC, CLE, CBE, IBCLC, etc.,

What type of perinatal support services do you offer?

Breastfeeding

Prenatal

Postpartum

Childbirth Education

Other

How do you provide these services?Select all that apply.

Virtual/Online

Texting

Telephone

In-Person

Other

Please share how long you have done this work and a brief description of how you serve your community.Be sure to include your mission and vision in 1500 words or less.

Are you currently providing any telehealth services?* This field is required.

YESNO

How many times are you providing telehealth services on a monthly basis?* This field is required.

1-3 times a month

4-6 times a month

7-9 times a month

10+ times a month

Not providing telehealth service at this time

Do you have access to a Facebook account?

Yes

If you are not currently providing telehealth services, do you plan to do so with this funding?

Yes

N/A

What funding level are you applying for?

$1000

$2500

$5000

How will you or your organization maximize funding to improve telehealth services?Select all that apply.

Improve access to virtual doula/CHW

Expand Prenatal/Postpartum clinical care via telehealth

Increase remote pregnancy monitoring

Increase access and affordability of technology up to 12 months postpartum

Virtual training to childbirth educators, lactation consultants to build capacity to use trauma-informed telehealth approaches

Other

Briefly describe how you will implement the strategies you selected in the previous question.

How can ROSE support you in distributing funds and resources to those you serve?

The Village Innovating Perinatal Services Cohort Application