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, 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.

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* 1. What is today's date?

Date

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* 2. Expectant/new mother's first and last name

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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

Date

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* 6. Contact Information

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

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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?

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* 10. Relationship status

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* 11. Do you have financial / money concerns?

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

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* 13. How did you hear about us?

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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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