Healthy Families Steuben/Livingston and Healthy Families Schuyler/Tompkins strive to talk with all new and expectant parents. Our goal is to identify strengths and challenges, and provide appropriate information to help babies get off to a healthy start. Our services are free and voluntary and your information is always protected.

If you are pregnant or have a baby under three months (or under 24 months if you are partnering with DSS), please complete the survey below and a staff member will contact you. For additional information on the program, please email healthy.families@dor.org

If we are unable to contact you, we may reach out to the referral source for updated contact information or for help in connecting you with a Healthy Families program in your area.

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1. What is today's date? (Required.)

Date

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2. Expectant/new mother's first and last name (Required.)

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3. Expectant/new mother's support person

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4. Expectant/new mother's support person's phone number

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5. Expectant/new mother's date of birth (Required.)

Date

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6. Contact Information (Required.)

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7. What is the best way to contact you?  (check all that apply) (Required.)

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8. Due date or birthday of your baby

Date

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9. When did you start receiving prenatal care? (Required.)

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10. Relationship status (Required.)

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11. Do you have financial / money concerns? (Required.)

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12. Are you receiving WIC, SNAP, Medicaid/Fidelis or any other NYS benefits? (Required.)

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13. How did you hear about us? (If you saw our online raffle, please indicate here)

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14. If you were referred by a current HFSL or HFST participant, please share their name below.

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