Safe & Sacred Care Intake
Please complete all applicable fields; fields are optional unless marked required, and some questions may depend on your answers.
Client Information
Acknowledgment
*
I understand that submitting this form is a request for review only and does not guarantee services.
Full name
*
First Name
Middle Name
Last Name
Relationship to person needing care
*
Please Select
Self
Parent or guardian
Spouse or partner
Family member
Healthcare professional
Other
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
*
example@example.com
Preferred contact method
Please Select
Phone
Text
Email
Best time to contact
Please Select
Morning
Afternoon
Evening
Is care for you?
*
Please Select
Yes
No
Client Information
Client Full Name
*
First Name
Middle Name
Last Name
City
*
ZIP Code
*
Preferred Pronouns
Preferred Language
Care Request Overview
Type of care requested
*
Maternal Nursing Care
Postpartum & Newborn Support
Doula Support
Lactation Support
Complex or High-Risk Pregnancy & Recovery Support
Private Duty / General Home Care
Health Education & Coaching
Care Coordination & Advocacy
Other
When should care begin?
*
Please Select
As soon as possible
Within 1 week
Within 2-4 weeks
Future date
Preferred care format
*
Please Select
In-home
Virtual when appropriate
Either
Brief description of support needed
*
Maternal Care Details
Current maternal stage
Please Select
Pregnant
Postpartum
Planning pregnancy
Other
Estimated due date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Delivery date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Delivery type
Please Select
Vaginal
Cesarean
Other
Prefer not to say
Multiple pregnancy or birth
Please Select
Yes
No
Currently receiving prenatal or postpartum care
Please Select
Yes
No
Provider type
Please Select
OB/GYN
Midwife
Family medicine
Maternal-fetal medicine
Other
Provider or practice name
Additional maternal support needs
Blood-pressure monitoring
Gestational diabetes education or support
Preeclampsia or hypertension support
Cesarean recovery
Post-operative recovery
High-risk pregnancy monitoring
Mental health / mood support
Infant loss or grief support
Birth trauma support
Other
Lactation Support Details
Who needs feeding support?
*
Please Select
Prenatal education
Newborn
Infant
Feeding method(s)
*
Breast/chestfeeding
Pumping
Bottle feeding
Combination
Unsure
Primary concern
*
Please Select
Latch
Pain
Milk supply
Pumping
Feeding plan
Weight gain
Weaning
Other
How soon is support needed?
*
Please Select
Urgent - today if available
1-2 days
This week
Future
Private Duty / General Home Care Details
Type of support needed
*
One-on-one nursing
Post-operative recovery
Medication support
Health monitoring
Personal care
Respite care
Companion care
Chronic condition support
Mobility / safety support
Other
Approximate frequency
*
Please Select
One-time visit
A few visits
Weekly
Multiple days per week
Overnight
Unsure
Existing physician/provider plan or order for requested nursing care
*
Please Select
Yes
No
Unsure
Payment and Insurance
How do you plan to pay for services? Some services may not be covered by your insurance we must be able to verify coverage.
*
Please Select
Private Pay
Commercial Insurance
Medicaid or Medicaid Managed Care
Other Insurance
Unsure - please help me determine
Would you like information about private-pay rates and care packages?
Please Select
Yes
No
Insurance company
Plan type, if known
Policyholder name
First Name
Middle Name
Last Name
Referral and Source Information
How did you hear about Safe & Sacred Care?
*
Please Select
OB/GYN or physician
Midwife
Hospital
Health department
Medicaid/MCO
Friend or family
Social media
Internet search
Community organization
Other
Were you referred by a professional or organization?
*
Please Select
Yes
No
Referral source name
May we contact the referral source or provider for care coordination after authorization?
*
Please Select
Yes
No
Emergency and Final Acknowledgments
Emergency disclaimer
*
Is this an immediate medical emergency?
*
Please Select
Yes
No
Acknowledgment: Information provided is accurate and complete
*
I confirm that the information provided is accurate and complete.
Acknowledgment: No nurse-patient/provider-patient relationship is guaranteed
*
I understand that no nurse-patient or provider-patient relationship is guaranteed.
Acknowledgment: Review and next steps
*
I understand that Safe & Sacred Care will review the request and contact me regarding availability, payment/coverage review, and next steps.
Electronic signature
*
Signature date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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