TEACUP Preemie Program® Request for Services

TEACUP Preemie Program® Request for Services

TEACUP Preemie Program® provides education, support, and resources to parents 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 preemie parent or a hospital partner/agency staff? *

Preemie Parent (madre o padre prematura) Hospital or Agency Staff

Mother's Name *

First Name Last Name
Mother's Date of Birth

Month Day Year
Date
Home Address *

Street Address

Street Address Line 2

City State

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

Primary (first) language *

English Spanish Haitian Creole Other

Can mom communicate comfortably in English? *

Yes No

Baby's Name *

First Name Last Name
Gender *

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

Yes No
Add Another baby? *

Yes No

Baby's Name *

First Name Last Name
Gender *

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

Yes No
Add Another baby? *

Yes No

Baby's Name *

First Name Last Name
Gender *

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

Yes No

REASONS FOR REFERRAL *

Emotional Support Education re: premature birth and development Financial Concerns (assess need for breast pump loan) Other

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

yes no

Has the mother contacted WIC? *

yes no unsure

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? *

Yes No

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 Preemie 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?) *

Yes No (we invite you to participate in our Preemie Parent Support Groups!)

How may we help you today? *

I would like to register to attend a Preemie Parent Support Group I would like to speak to someone from TEACUP regarding professional support with the premature birth of my baby I'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 Thursdays at 6:00pm

Your Name *

First Name Last 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 Name Last Name

Your Baby's Name *

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

Female Male
Is baby still in NICU? *

Yes No
Add another baby? *

Yes No

Your Baby's Name *

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

Female Male
Is baby still in NICU? *

Yes No
Add another baby? *

Yes No

Your Baby's Name *

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

Female Male
Is baby still in NICU? *

Yes No

How did you find out about TEACUP Preemie Program? *

From a NICU nurse at the hospital From a lactation consultant at the hospital From another health provider From a friend Internet search Other

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

Yes No
May we use photos of you taken during group in our social media and advertising? *

Yes No
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 agree No, I opt out of attending the group

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

Clear
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TEACUP Preemie Program® 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