NEW SHIFRA ONBOARDING

Welcome to the SHIFRA Family!

These questions will help us understand your needs and empower your journey.
SHIFRA is here to nurture you through your pregnancy crisis and equip you to flourish as a mother. Your open and honest answers will allow us to customize our support for your journey.

This assessment will help guide our counselors and our care team. Your SHIFRA Counselor will help nurture and strengthen you for your motherhood journey. Our Care team (Menucha and Carol) help you solve specific problems through SHFIRA resources and community resources.

PLEASE NOTE: This is a needs assesment, not a financial aid application. You can only apply for financial aid after we have spoken to your references.
Basic Information
What is your name?*

First NameLast Name
When is your birthday?*

MonthDayYear
Date
What is your mailing address? (No PO Box)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Email
example@example.com
Your Cell Phone Number

Area CodePhone Number
How did you find out about SHIFRA?*

Google SearchInstagram AdYoutube AdFriend or FamilyOther Search EngineReferral from other non profitOther
Please provide additional information about your referral from a non-profit or friend (e.g., the name of the non-profit or how your friend heard about us).
Pregnancy Background
Are you currently pregnant?*

YesNo
Are you currently pregnant with twins/multiples OR have you had multiples in the past? If you already have twins/mutiples, please state their age.*
How many weeks pregnant are you? *
When is your due date? *

MonthDayYear
Date
When was your baby's birthdate?*

MonthDayYear
Date
Which of the following applies to you?*

I was considering abortion/ under pressure to abort when I called SHIFRAI ruled out abortion before I called SHIFRAI didn't want to be pregnant, but I didn't consider abortionI wanted to be pregnant but crisis occurred after I became pregnant
Which Scenario Best Describes Your Pregnancy?*

Hormonal, IUD or Barrier birth control failedOther (rhythm/natural family planning method) birth control failedNo birth control, because I believed I wasn't able to become pregnantIntended pregnancy, but new crisis occurred since pregnancy
Relationship Status*

MarriedInvolved with/Living with Baby's FatherSeparated/Divorced from Baby's FatherSingle, Baby's Father Not InvolvedOther
Do you have other children?*

No, this is my first babyYes, I have other children
How many children currently live with you?
Do any of your children have special needs?

Yes, children with special needs living meNo
Do you have children who do not live with you?

NoYes, they live with father/otherYes, they are adultsOther
Number of your kids who don't live with you
Emergency Contact

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Emergency Contact Relationship
Please list two days of the week / times of day **between 9am- 9 pm Eastern** that are generally best for you to talk to your counselor. (Example- Tuesday at 2 pacific, Thursday at 7 pm Central.)
MOMMY WELLNESS & EDUCATION
What strengths have helped you accomplish your goals in the past? What accomplishments are you proud of?
How have you been feeling about your pregnancy? Please check all that apply, whether you feel this way now or felt this way before contacting SHIFRA.

Numb/disconnected from baby.Angry about being pregnant when I didn't want to beDepressed/hopeless about pregnancyOverwhelmed by my other responsibilities/mostly ignoring I'm pregnantAnxious/afraid about responsibility of having a baby or another babyHopeful or excited about pregnancy despite challengesDetermined to overcome obstacles
Are you experiencing any of these external crises?

Spouse/partner or family pressuring me to abort/ refusing to support me if I have babyLeaving/Need to Leave Abusive SituationHomeless or At Risk of HomelessnessCurrently unemployed or partner is unemployed/ can't make ends meetPregnancy Health Conditon requiring Mandatory BedrestRecent or Impending Breakup/Divorce with baby's fatherOther
Are you experiencing any of the following during this pregnancy?

I've been diagnosed with hyperemesis gravidarum (HG)Vomiting more than twice a dayNausea that make you drink less than 6 cups of fluid per dayNausea that makes you eat 1/3 less or more than normal
What are you biggest fears concerning this pregnancy?
Would you like help releasing negative feelings towards pregnancy?

YesNo
Would you like help developing positive feelings towards baby?

YesNo
Do you want help with implementing more self-care practices?

YesNo
Do you need Prenatal Birth Classes (What to expect in birth process)?

YesNo
Do you need to learn Baby-Care Skills?

YesNo
We have a professional prenatal educator, Chava Algood, who offers classes to SHIFRA clients free of charge. May we share your name with her?

YES, you have my permission to share my information with Chava Algood, so I can attend her Birth & Baby Care classes.NO, thank you, don't need prenatal class.
Do you want coaching on parenting your other children?

YesNoNot Applicable
Biggest fears/concerns with the baby.
How confident are you as a mother/future mother?*

1 - I feel like I’m unequipped to handle a baby and/or failing my other kids2 - Somewhat lacking confidence3 - I'm unsure4 - Mostly confident in my ability5 - I know I'm a good mother who can meet my future child (and current children's) needs
What are your strengths as a mom?
Which self-care practices do you engage in? Select all that you do at least once a month.

I don’t — I’m so stressed/exhausted that I barely manage basics like brushing my teeth or showering.I make sure to go to regular doctors/dental appointments regularlyI exercise or dance (at home, gym, formal, or informal).I take walks or spend time in nature.I make time to play and relax with people I love.I journal, do art, or spend time on creative activities.I take hot baths.I do crosswords or play games online just for fun.I spend time talking with or enjoying the company of close friends who truly listen.Other
Do you need maternity clothes?

YesNo
Please let us know your pre-pregnancy size, clothing preferences (e.g., no pants, etc.), and any specific requests you may have.
FINANCIAL STABILITY
What describes your current financial and educational situation? (SINGLE)

I am unemployedI am in school, not workingI am working in my goal careerI am working to make ends meet, not in goal career
What describes your current financial situation? (MARRIED OR SEPARATED)

I am working but not in goal careerI am working in my goal careerI am a studentI am stay at home-momI am unemployedMy husband/partner is unemployedmy husband/partner is working full-timeOther
How long have you been unemployed?
How long have you been attending school?
If working, are you working:

FulltimePartime
What is your current average monthly income?
Current monthly rent/mortgage amount:
What are your current monthly childcare & school costs for your other children? (Please exclude scholarships or subsidies.)
Would you like to work with counselor on creating a budget for when baby comes?

Yes,No, I got a budget already/don't need one
If you are not working in goal career, what would help you enter goal career, how much would your goal career make?
Are you currently receiving any government/non-profit aid

MedicaidSNAPCash Benefits (Temporary Assistance Need Families/Welfare)WICChild Care VoucherOther
We encourage you to work with other agencies besides SHIFRA if needed! Please list any and all non-profits or government programs you are currently working with or benefiting from. We want to put together a team to support you and need to know who else is on your team! Put N/A if not applicable*
Preparing for Baby: Support Network
Does you spouse/partner supports this pregnancy?

YesNoUnsure
Do you want coaching around communication/partnering with your spouse around new baby/childbearing?

YesNo
What childcare support situation do you currently have? (Check all that apply).

Household helpFamily living nearbyFriends (e.g., carpooling)Other
What do you use to obtain second hand child/baby equipment or clothing? (Check all that apply).

Friends or familyBuy Nothing groupsMommy groupsSecondhand/consignment shopsOther
Which friends or family (if any) could you get gently used equipment or clothes from?
(Sister, Mom, Cousins, Close Friends, Church Friends, etc..)
Which items will you need? (Check all that apply)

Car seatStrollerCribOther
Do you have network of friends who are moms?

YesNoOther
Do you have family or friends who might help during birth or your transition after birth (either nearby or with whom you could stay)?

YesNoOther
Do you have family or friends who could help with babysitting or childcare when you return to work/school?

YesNoOther
Which family or friends who will want to give presents for the baby? Which if any, might be able to give gently used items? (crib, clothes, stroller, car seat, etc..)
Which family/friends recently had babies and could mentor you on newborn care?
Do you currently have household help? If so, how much do you pay monthly?
Put n/a if none.
Who is in your support network?*

My momMy dadMy siblingsMy husbandMy boyfriend/partnerI have good friends I can count onMy Rabbi/RebbetzinMy therapistGrandparentAunts, Uncles or CousinsOther
Please share how you feel you can lean on people in your support network.*
Please rate current quality of your key relationships (spouse, partner, ex, parent, friend, etc.) on a scale from 1-10, with 1 being poor and 10 being excellent. (EXAMPLE: My ex-boyfriend/baby's father- 3, My son Joey- 5)
Other goals — If there are other goals you would like our help with (like leaving an unhealthy relationship) please share here:*
Are you currently receiving support from a therapist, psychologist, or psychiatrist for a clinical diagnosis (such as bipolar disorder, OCD, anxiety, or depression)?*

YESNOOther
Therapist/Psychiatrist Name:

First NameLast Name
Therapist/Psychiatrist Phone Number:

Area CodePhone Number
SHIFRA COUNSELING DISCLAIMER

SHIFRA offers our clients free counseling from their first trimester through their baby’s first birthday. SHIFRA counselors are licensed clinical social workers who can help clients navigate their pregnancies and motherhood journeys, including its many ups and downs. SHIFRA Counselors can help our clients embrace your pregnancy and bond with their babies, increase emotional resilience, well-being and self-care, increase quality of their relationships and parenting, and help clients make action plans and identify resources.

SHIFRA Counselors cannot treat mental health conditions such clinical depression, chronic anxiety, OCD, bipolar disorder or any other mental health or medical condition.

SHIFRA Counselors cannot replace the professional advice and guidance of doctors, nurses, lawyers, or domestic abuse agencies.

SHIFRA Counselors cannot serve as therapists if Child Support Services is requiring a client to work with therapist.
Waiver Statement: 1. I have read and understand the "SHIFRA Counseling Disclaimer" statement above. 2. I understand that SHIFRA's Counseling cannot be used to replace in-person psychotherapy for treatment of mental health conditions. 3. I understand that I will be referred to other mental health professionals if I need them. 4. I also understand SHIFRA staff are not doctors or legal professionals. I agree that I will seek the help of mental health, medical or legal professionals if I need to. 5. If applicable, I agree that I will immediately disclose any mental health or psychiatric diagnoses to my SHIFRA counselor so she can better support me. I understand that the failure to disclose mental health or psychiatric conditions or diagnoses are grounds for SHIFRA terminating services with me because SHIFRA cannot provide counseling services that are not coordinated with guidance of therapists or psychiatrists if there is any mental health or psychiatric diagnoses. 6. I agree that I am responsible for making my own decisions, including the decision to raise my child or place for adoption, and for all consequences of those decisions. 7. I agree to hold SHIFRA harmless and free from liability with regard to anything arising from my decisions. 8. I understand that any dispute arising from my relationship with SHIFRA will be addressed in court in the State of Maryland.

YES, I understand and agree to all parts of waiver above.
Information Release Statement: With this signature below, I am authorizing SHIFRA to share with my therapist/psychiatrist about the support I am seeking from SHIFRA and I am authorizing release of information regarding my mental health history, including any psychological or psychiatric information relevant to counseling and services sought from SHIFRA. The release is for the specific purpose of verification of my situation and coordinating services. I understand this authorization will expire when I cease to use SHIFRA services.*

YES, I understand and agree that SHIFRA can call my therapist or psychiatrist for the purposes of coordinating services.Not applicable, because I do not have a therapist or psychiatrist at this time and I also do not have any mental health diagnoses.Other
Signature*

Clear
Financial Aid Information

PLEASE NOTE: The information above are a needs assessment- not a financial aid application. Generally clients do not apply for financial aid until 2nd or 3rd trimester. Before you can apply for SHIFRA financial aid, we must check your references. If you know you don't need financial aid- just social and emotional support- feel free to skip this section! For those who will want to apply for financial aid, we ask for two references in case one is unreachable. But if you only have one at this time, please include. Acceptable references for financial aid are social workers from other agencies (Jewish family services), rabbis, and rebbetzins.
REFERENCE AND FINANCIAL AID:*

I do not plan on asking for financial aid, so I will not be submitting a reference.I do plan on asking for financial aid and am submitting reference below.I do want to ask for financial but am unsure who can be reference. I will fill out this information at a later time. I understand I can't apply for financial aid until reference check is complete.
Reference #1 - Name*

First NameLast Name
Reference #1- Organization Name*
Reference #1 Office Phone Number*

Area CodePhone Number
Reference #1 Cell Phone Number (if applicable) *

Area CodePhone Number
Reference #2 Name*

First NameLast Name
Reference #2 Org Name*
Reference #2 Phone Number= OFFICE (IF applicable)*

Area CodePhone Number
Reference #2 Phone Number- CELL (If applicable)*

Area CodePhone Number
I authorize SHIFRA to exchange information with the reference contacts designated above any relevant information pertaining to meeting my emotional and financial needs. If this reference is Rabbi or social worker, I am authorizing release information about my financial situation and other services I am receiving. The release is for the specific purpose of verification of my situation, services planning and continuity of care. I understand this authorization will expire when I cease to use SHIFRA services.
Email Address*
Email Address of the Person Submitting This Form
Signature*

Clear
Unique ID #*
Thank you so much. It is our privilege at SHIFRA to help you navigate your journey. One step at a time, you are working to develop your plan. You are on your way to becoming the woman and mother you want to be.
Should be Empty:

Welcome to the SHIFRA Family!

Basic Information

Pregnancy Background

MOMMY WELLNESS & EDUCATION

FINANCIAL STABILITY

Preparing for Baby: Support Network

Financial Aid Information