New Family Intake Form

New Family Intake Form

Whether you are an expectant parent with a prenatal diagnosis, or a new parent of a baby with Down syndrome, the Down Syndrome Network of West Virginia (DSNWV) is here to support you! By answering a few questions, we can match you with a trained parent mentor to help you through your diagnosis journey.
What we provide:

The DSNWV can match you with a trained parent mentor who has a young child with Down syndrome. We will also send you some resources about Down syndrome and some helpful programs West Virginia has to offer. All information is kept confidential, and our mentors have been professionally trained by the Massachusetts Down Syndrome Congress' First Call Program in conjunction with the DSNWV.
About You
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
I am:*

a new parentthe spouse, significant other, or family member of a new parentadoptive parentfoster parent
About Baby
Baby's Name*
If prenatal or unnamed type "not yet named"
Baby's sex*
Baby's date of birth*

MonthDayYear
If prenatal select due date
Please indicate any testing you or baby have had done:*

Prenatal screening with positive results: Ultrasounds, mother's blood tests, Cell-Free DNA (cfDNA)Prenatal diagnostic with positive results: Amniocentesis, Chorionic Villus Sampling (CVS)Genetic testing of baby after birth: Fluorescence In Situ Hybridization (FISH), Karyotype (chromosomal analysis)NoneOther
Optional Additional Information

This can help us make the most meaningful connection when possible
Age of new mom/parent
Ethnicity of Parent(s)
Language(s) spoken by parents/in the home
Please describe any relevant health information of mom/baby that may be helpful for us in offering the most meaningful support and resources. For example, if baby has a heart condition or extended NICU stay.
Please provide any relevant background information or family structure that may be helpful for us in offering the most meaningful support and resources. For example, ages of any siblings or involvement/estrangement of family members.
We are here for you!

We have several trained parent mentors ready to support you. These parents offer a safe, confidential space to connect, share, and feel supported.
Would you like to be contacted by a First Call Parent Mentor?*

YesNot at this time
If YES, how would you like the initial contact to be made?

Phone callTextEmail
If you are NOT ready to be contacted, may we mail you a DSNWV Welcome Packet that includes resources, information, and gifts for baby?

YesNot at this time
Anything else you'd like to share?
Lastly, please tell us how your heard about DSNWV

Online searchSocial MediaMedical ProviderFamily/Friend of a child with Down syndromeOther
Consent Form
Consent

I have reviewed the waiver and consent below
Down Syndrome Network of West Virginia (DSNWV) First Call Program Waiver/Consent:

I understand that I will be speaking with a trained parent volunteer and that this conversation does not represent medical advice or professional counseling. The DSNWV does not provide advice in any way. My conversation(s) with a parent mentor will be confidential, and only a brief synopsis of our call(s) will be shared with the DSNWV Family Support Team to ensure individualized resources and supports are provided to me. My personal information will not be shared and will be kept confidential within the DSNWV Parents First Call Program.
Should be Empty:

New Family Intake Form

What we provide:

About You

About Baby

Optional Additional Information

We are here for you!

Consent Form