TEACUP® Request for Services

TEACUP® Request for Services

TEACUP® provides education, support, and resources to parents who have a baby in the NICU or who have given birth to a premature infant (preemies are babies who are born before they reach 37 weeks gestation).
At the time of birth, how many weeks gestation was the baby? (Al momento del nacimiento, ¿cuántas semanas de gestación tenía el bebé?)*

Thank you for considering TEACUP Preemie Program.

TEACUP is for families of premature infants, born before 37 weeks gestation. To learn more about the other programs of The Children's Healing Institute, please call 561-687-8115 or visit us at www.ChildrensHealingInstitute.org

Are you a parent or a hospital partner/agency staff?*

Parent (madre o padre)Hospital or Agency Staff

Mother's Name*

First NameLast Name
Mother's Date of Birth

MonthDayYear
Date
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mobile Number*
Please enter a valid phone number.

Primary (first) language*

EnglishSpanishHaitian CreoleOther

Can mom communicate comfortably in English?*

YesNo

Baby's Name*

First NameLast Name
Gender*

MaleFemale
Birth Weight: Pounds* Ounces*
Is the baby still in NICU?

YesNo
Add Another baby?*

YesNo

Baby's Name*

First NameLast Name
Gender*

MaleFemale
Birth Weight: Pounds* Ounces*
Is the baby still in NICU?

YesNo
Add Another baby?*

YesNo

Baby's Name*

First NameLast Name
Gender*

MaleFemale
Birth Weight: Pounds* Ounces*
Is the baby still in NICU?

YesNo

REASONS FOR REFERRAL*

Emotional SupportEducation re: NICU, medical issues, premature birth and developmentFinancial Concerns (assess need for breast pump loan)Other

Does the mother qualify for a pump loan from WIC?*

yesno

Has the mother contacted WIC?*

yesnounsure

This mother can contact WIC to schedule an appointment to inquire about receiving a hospital-grade breast pump to borrow while the baby is hospitalized. The central appointment line for WIC is 561-357-6007.

Select "Next" to continue with your referral.

Was the parent/guardian informed of the TEACUP® program and did they give verbal consent to be referred for services?*

YesNo

Please speak with the parent(s) about TEACUP prior to submitting this referral. We are not able to contact parents regarding services unless you indicate with your signature that you have discussed the program with them and obtained verbal consent.

Comments:
By signing this form, I confirm that I, the referring party, have discussed TEACUP® services with the named individual being referred to the program, and have received her verbal consent to be contacted by TEACUP Program® at The Children's Healing Institute.*

Clear

Are you currently residing or staying in Palm Beach County? (¿Vives en el condado de Palm Beach?)*

YesNo (we invite you to participate in our NICU/Preemie Parent Support Groups!)

How may we help you today?*

I would like to register to attend a NICU/Preemie Parent Support GroupI would like to speak to someone from TEACUP regarding professional support with the hospitalization or premature birth of my babyI'm not sure yet. Can someone call me and let me know more?Hablo solo español. ¿Alguien puede contactarme?
All groups are virtual at this time. Which group (or groups!) are you interested in attending?*

Mondays (Lunes) at 6:00pm (en espanol)Tuesdays at 12:00pm (NICU & preemie parents)Thursdays at 6:00pm (preemie parents)

Your Name*

First NameLast Name
Your Phone Number*
Please enter a valid phone number.
How can we help you? (Please include as much info as you like about your baby, when he/she was born, etc.) / ¿Como podemos ayudarte? (Incluya cualquier información que desee sobre su bebé, cuándo nació, etc.)*

Let's get to know you and your baby (or babies)!
Your Name*

First NameLast Name

Your Baby's Name*

First NameLast Name
Birth Weight: pounds* , ounces*
Baby's Gender*

FemaleMale
Is baby still in NICU?*

YesNo
Add another baby?*

YesNo

Your Baby's Name*

First NameLast Name
Birth Weight: pounds* , ounces*
Baby's Gender*

FemaleMale
Is baby still in NICU?*

YesNo
Add another baby?*

YesNo

Your Baby's Name*

First NameLast Name
Birth Weight: pounds* , ounces*
Baby's Gender*

FemaleMale
Is baby still in NICU?*

YesNo

How did you find out about TEACUP Preemie Program?*

From a NICU nurse at the hospitalFrom a lactation consultant at the hospitalFrom another health providerFrom a friendInternet searchOther

Group Consents
May we text you to remind you of upcoming groups and events?*

YesNo
May we use photos of you taken during group in our social media and advertising?*

YesNo
VIRTUAL SUPPORT GROUP AGREEMENT: Group starts promptly at the beginning of the hour. Zoom group will open 5 minutes prior to start time. Please be on time so you get the benefit of a full hour together.Group also ends on time. We appreciate and respect the time that you are each taking out of your day for yourselves and your peers, and we will honor that by ending group on time.Attendees will be admitted into the group until 15 minutes after the hour. After that, no one else will be admitted, so as to preserve the flow of the group in progress. Although parents are experts at multitasking, we encourage you to give other group members your full attention during this hour.Mute your line unless you are speaking, so that everyone can clearly hear the person actively speaking.All sharing is confidential. Whatever is shared in the group stays in the group.Everyone has the opportunity to share safely and equally. We ask that everyone is mindful to listen as much as they share and to not interrupt others while they speak.The focus of the group is to listen, feel heard and understood while sharing strategies, rather than “advice-giving”Please know that the facilitators are master’s level clinicians and mandated reporters if ever we are told or have reason to believe that someone is not safe.

Yes, I agreeNo, I opt out of attending the group

Consent to be Contacted
I authorize TEACUP to contact me to coordinate services. With my signature below, I hereby give my consent.*

Clear
Should be Empty:

TEACUP® Request for Services

Thank you for considering TEACUP Preemie Program.

This mother can contact WIC to schedule an appointment to inquire about receiving a hospital-grade breast pump to borrow while the baby is hospitalized. The central appointment line for WIC is 561-357-6007.

Please speak with the parent(s) about TEACUP prior to submitting this referral. We are not able to contact parents regarding services unless you indicate with your signature that you have discussed the program with them and obtained verbal consent.

Let's get to know you and your baby (or babies)!

Group Consents

Consent to be Contacted