In Collaboration with Lower Hudson Valley Perinatal Network
"It's About You!" and Healthy Families Rockland County Programs
 
We service families and children by providing an array of support services, including but not limited to:
  • Prenatal and Postpartum Services and Education
  • Child growth and Development
  • Home Visiting Services for Pregnant Women
  • Breastfeeding Support Medical Care
  • Father Support Services
Please fill out the information below. Are you ready to begin?

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* 1. Participant's Information:

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* 2. In what language does participant speak most fluently?

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* 3. What is participant's race/ethnicity?

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* 4. What is their marital status?

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* 5. Is the participant pregnant?

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* 6. When is their due date or baby's date of birth?

Due Date/Child's date of birth

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* 7. When was their first prenatal visit?

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* 8. Does participant qualify for TANF/Medicaid/WIC?

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* 9. We provide FREE support services for our families. Please put a check mark next to the resources they would like to learn more about:

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* 10. Provider Information:

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* 11. Please note reason for referral/needed services and special instructions to contact (if any):

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* 12. Does the participant agree to be referred to a home visiting program based on eligibility criteria and give permission to the release of the above information to Lower Hudson Valley Perinatal Network "It's About You!" and Healthy Families Rockland County?

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* 13. What is today's date?

Date
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