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).

  • 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?*
  • Hospital or Agency*
  • Format: (000) 000-0000.
  • Mother's Date of Birth
     - -
  • Format: (000) 000-0000.
  • Primary (first) language*
  • Can mom communicate comfortably in English?*
  • Birth Hospital*
  • How was baby born?*
  • Date of Birth*
     - -
  • Gender*

  • Birth Weight:   *   *  

  • Is the baby still in NICU?
  • Add Another baby?*
  • Gender*

  • Birth Weight:   *   *  

  • Is the baby still in NICU?
  • Add Another baby?*
  • Gender*

  • Birth Weight:   *   *  

  • Is the baby still in NICU?
  • REASONS FOR REFERRAL*
  • Does the mother qualify for a pump loan from WIC?*
  • Has the mother contacted WIC?*

  • 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?*

  • 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.

  • Are you currently residing or staying in Palm Beach County? (¿Vives en el condado de Palm Beach?)*
  • How may we help you today?*
  • All groups are virtual at this time. Which group (or groups!) are you interested in attending?*
  • Format: (000) 000-0000.
  • Baby's Birth Hospital*
  • Is baby still in NICU?*

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

  • Format: (000) 000-0000.
  • May we text you?*
  • Your ethnicity (this information is used in reporting to our funders regarding the populations we serve)*
  • What is your primary language?*
  • Can you communicate comfortably in English?*
  • Baby's Birth Hospital*

  • Birth Weight: * , *

  • Baby's Gender*
  • Is baby still in NICU?*
  • Add another baby?*

  • Birth Weight: * , *

  • Baby's Gender*
  • Is baby still in NICU?*
  • Add another baby?*

  • Birth Weight: * , *

  • Baby's Gender*
  • Is baby still in NICU?*

  • Group Consents

  • May we text you to remind you of upcoming groups and events?*
  • May we use photos of you taken during group in our social media and advertising?*
  • 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.
  • How did you find out about TEACUP Preemie Program?*

  • Consent to be Contacted

  • Should be Empty: