Community Home Visitor Self-Registration Form
THIS FORM IS ONLY FOR A REFERRAL to our Community Home Visitor Program. If you have filled this out do not fill it again we will get to you when we can as we have many referral request. If you are already connected with us, you do not need to register, just reach out to us.
Please fill out the form below to be referred to our home/community visitor programs. A midwife will connect with you and visit you in the community (hospital, home or shelter). We will try to accommodate all requests and contact you within 5 to 7 days to let you know if you qualify and see you in the community. All questions asked are confidential and used to understand what service you may need and to help us improve our services. If you need to be seen sooner, please visit us during our walk-in clinic or book an appointment.
Your name
*
First Name
Last Name
What is your date of birth
*
-
Day
-
Month
Year
Date
Phone Number
*
Please enter a valid phone number that we can contact you at
Format: (000) 000-0000.
Can we to leave a voicemail on this phone number?
*
Yes
No
Email
*
example@example.com
What type of insurance do you have?
*
OHIP
IFH
Uninsured
Student insurance UHIP
Out of province insurance
Other
What pronouns do you use?
Please Select
she/her
he/him
they/them
shethey
he/them
How many times have you been pregnant (please include this pregnancy and any other prgnancies)?
*
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16+
How many vaginal births have you had?
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16+
How many times have you had a c-section?
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16+
How many VBAC's (Vaginal Birth After C-section) have you had?
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16+
How many miscarriages and/or abortions have you had?
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16+
How many baby(babies) have you had pass away?
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16+
To understand what care and support you need today, please answer the following:
*
I am currently pregnant
I have just given birth (me and my baby are 8 weeks or less)
I have just had a recent loss (8 weeks or less)
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Address
*
Street Address
Apartment
City
State / Province
Postal / Zip Code
Pregnancy Care
Please answer the following questions so we can help support you
Do you currently have a healthcare provider for the pregnancy?
*
Please Select
Midwife
Obstetrician
Family Practitioner
Have None
What is your EDD (Estimated Due Date)?
*
-
Month
-
Day
Year
Date
Are planning of given the baby/babies up for adoption?
*
yes
No
How many babies are you pregnant with?
*
Please Select
1
2
3
4
5
What type of delivery are you hoping to/planning to have?
*
Please Select
Vaginal
TOLAC (Trial of labour after c-section)
Planned or Repeat c-section
Do you have any pregnancy concerns or risk factors?
*
Yes
No
What concerns or risk factors do you have?
*
Does your baby have any concerns?
*
Yes
No
What concerns or risk factors does your baby have?
*
How are you planning on feeding your baby?
*
Please Select
Breastfeeding/Chestfeeding
Formula
Combination
Unsure need more information
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Next
Do you have a care provider for your postpartum?
Please Select
Midwife
Obstetrician
Family Doctor
Registered Nurse Practitioner
Postpartum Care
Please answer the questions regarding you and your baby
When did you give birth?
*
-
Month
-
Day
Year
Date
Have you recently given birth in the last 8 weeks?
*
Yes
No
How many babies did you give birth to?
*
Please Select
1
2
3
4
5
Was the baby baby adopted and no longer in your care?
*
Yes
No
Do you have any risk factors or concerns in your postpartum?
*
Yes
No
What concerns or risk factors do you have?
*
Does your baby have any risk factors or concerns?
*
Yes
No
What concerns or risk factor does your baby (babies) have?
*
How are you feeding your baby?
*
Please Select
Breastfeeding/Chestfeeding
Formula
Combination feeding
Still figuring out need more information
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Next
Loss Support
We understand that this can be a hard subject to discuss. Please try your best to answer the questions so we will be able to help support you.
Can you tell us the following
*
I had a miscarriage
I had an abortion
I lost my baby during pregnancy then gave birth
I lost my baby after giving birth (8 weeks ago)
When did you have your loss or give birth
*
-
Month
-
Day
Year
Date
How many babies did you lose?
*
Please Select
1
2
3
4
5
Was there any concerns, or risk factors during your pregnancy, labour or birth?
*
Yes
No
Please explain any conditions or situations regarding your pregnancy/birth
*
Is this your first loss or abortion?
*
Yes
No
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If we are unable to see you at home you can request a virtual and/or in person visit at our clinic. Please select all the best options for us to connect with you for the appointment.
*
Virtual (phone)
Virtual (video)
In person (at our clinic)
Please identify your Racial background
*
Black
African
Caribbean
Native American
Hispanic
South Asian
East Asian
White
Mixed race
Other
What language(s) do you speak
please list the language you communicate most in.
What is your house hold income level
*
Please Select
less than $10,000
$10,001 to 25,000
$25,001 to $50,000
$50,001 to $75,000
$75,001 to $100,000
$100,001 -$150,000
$150,000+
How did you hear about this program
*
Please Select
Facebook
YouTube
Instagram
X
Google search
Family or Friend
Healthcare provider
Community Centre
Hospital
Other
Please verify that you are human
*
Submit
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