FCPC self referral

Sign up for Family Connects nurse support

If you live in Pierce County and you are pregnant or have an infant less than 12 weeks old, use this form to request free, post-birth support from a Family Connects nurse. (If you are still pregnant, we can take your information and will reach out to say hello, but the visits don't start until after you give birth.) Certain zip codes automatically qualify for Family Connects; others may be eligible depending on nurse availability. We will call you and let you know either way if you qualify! This form uses encryption technology so your protected health information will be kept private. For questions, email info@familyconnectswa.org.
Your family's information

Please tell us a little bit about your family, so we can contact you and schedule.
Parent or primary caregiver's name*

First NameLast Name
Parent or primary caregiver's date of birth*

MonthDayYear
Date
Child's name*
It's okay to write boy, girl, surprise, etc if you don't know yet
Child's date of birth (or estimated due date if still pregnant)*
Address (include street, city)
Zip code*
Phone number(s)*
Preferred language

EnglishSpanishOther
Your healthcare

Please give us a little information about the healthcare you are receiving so we know where to look for information, and can possibly introduce ourselves in person at the time of birth.
Prenatal care provider
Your doctor/midwife, or name of the clinic or group
Pediatric provider if known
Who the baby sees (or will see) for well-child visits
Where did (or will) you give birth?*

Tacoma GeneralSt. Joseph Medical CenterMidwifery Birth Center at St JosephGood SamaritanMadigan Army Medical CenterBirthing InnHomeOther
Are you currently receiving Maternity Support Services? (Some people can receive both).

Yes, through AnswersYes, through Step By StepYes, through other (or uncertain which)UnsureNo
Insurance provider
Write "none" if uninsured
Is there anything else you'd like to share with us?
How did you hear about Family Connects?
By pressing submit, I acknowledge that this information will be shared with the implemeting agencies of Family Connects Pierce County which may include HopeSparks Family Services, Answers Counseling, and/or Step by Step Family Support.
Parent or primary caregiver's name
This may be the birth parent or another individual
Should be Empty:

Sign up for Family Connects nurse support

Your family's information

Your healthcare