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Family Needs Assessment
Wellness Within Reach
Full Name
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PRENATAL QUESTIONS: Complete the following questions if you are pregnant. If you are not pregnant skip to the postpartum questions. Are you pregnant
*
Yes
First delivery
No
If yes, what is your Due Date?
*
Are you interested in a home birth midwifery services and/or information?
Yes
No
Are you interested in birth center information and/or options?
Yes
No
Are you interested in free birthing?
Yes
No
Are you interested Doula support?
Yes
No
POSTPARTUM QUESTIONS: Are you postpartum?
*
Yes
No
Other
What type of birth did you have?
*
Vaginal
C-section
Infant loss
Miscarriage
Baby Gender?
*
Male
Female
N/A
Twins/Multiples
Are you breastfeeding?
*
Yes
No
Weaning
Are you in need of postpartum support?
Yes
No
If yes, what type of support would be helpful?
Are you in need of any of any of the following items to help you maintain, improve and/or monitor your health while pregnant and/or postpartum?
Blood pressure cuff
Fetoscope
Doppler
Breast pump
Prenatal vitamins
Glucose sticks and/or lancets
Belly band
Nursing bra
Bus passes
Car seat
Stroller
Other
If other please specify below.
Are you in need of any of the following resources to participate in telewellness services offered through MODABA?
Cell phone
Tablet
Hot spot
Pre-paid minutes/phone service
Pre-paid data/internet service
Headphones
Surge protectors
Ethernet cords
Headphones
Other
If other please specify below.
FAMILY FOOD & NEEDS QUESTIONS: Do you have enough food?
*
Yes
No
Do you have enough healthy food to feed yourself and your family?
Yes
No
Are you vegetarian?
Yes
No
Do you consume animal products?
Yes
No
Do you need emergency assistance?
Yes
No
Are you in need of any other type of assistance?
Yes
No
If no please list what food items and/or staple goods would be helpful.
How many individuals are in your household?
1-3
3-5
More than 5
What are their ages:
0-1
2-4
5-7
8-11
12-17
18-25
26-35
40+
65 and older
Do you receive food stamps?
*
Yes
No
Do not qualify
The amount is not enough.
Do you need assistance completing the AHCCCS application?
Yes
No
Are you interested in learning how to grow your own food?
Yes
No
Do you feel like you know how to make tasty, healthy meals from produce/fresh fruits and veggies?
Yes
No
Do you currently have a garden?
Yes
No
HEALTH & WELLNESS: Do you have a primary physician?
*
Yes
No
Are you interested in tele-health wellness classes/options?
*
Yes
No
Race/ethnicity?
*
Please Select
Black
Latino
African descent
Middle-Eastern
Caribbean
Afro/Latino
Other/Mixed
Are you interested in wellness classes
*
Please Select
Yes
No
Please identify which classes you'd be interested in.
Prenatal yoga
Postpartum yoga
Childbirth education
Grounding, Playing, Focusing
Breastfeeding
Nutrition
Fatherhood
Men's Health & Wellness
Homebirth 101
Cooking
COVID
Pregnancy Health
Postpartum Health
Fertility
One on One
Groups
Other
Would a male focused support group that includes topics of fatherhood and wellness be beneficial?
*
Yes
No
What days are you available to participate in our Tele-health wellness education classes?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What times work best for you to attend Tele-health virtual classes?
*
9:00am-12:00pm
1:00pm-3:00pm
3pm-5pm
After 5 pm
Which do you prefer?
*
In person private session
In person small group session
Online
What classes would you like to see offered?
Please list any additional information you would like us to know to better support you and/or list any additional resources you may need that were not identified above.
Would a $50 donation per month be affordable to access unlimited monthly classes, one 1:1 visit/meeting (if needed) and/or 1 group class (if interested) be affordable? Please respond and share any additional information below.
*
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