Healthy Families Shasta Questionnaire Healthy Families Shasta County Questionnaire Each parent needs someone to talk to as they care for a new baby. A Family Support Worker from Healthy Families Shasta County will give you the support that every parent deserves. If you are far from family and friends… if you want to come to free, fun events… if you want to be the best parent you can be, but aren’t sure how… if you have financial worries or other stresses in your family life, or other small children, we can help. Our home visitors come to you, at your convenience, to provide support and information to help your family adjust to life with a new baby. Home visitors help you with any challenge that may come during your pregnancy or with the ever-changing demands of parenthood. You tell us how we can best help you and your family. If you’d like to find out if you’re eligible for the free services provided by the Healthy Families Shasta County home visiting program, please complete and submit this form. Date MM slash DD slash YYYY Your Name* First Last Estimated Due Date MM slash DD slash YYYY Baby's date of birth if already arrived MM slash DD slash YYYY Your Date of Birth* MM slash DD slash YYYY Phone*Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Where do you plan to deliver (hospital name or other)? How did you hear about us?*FriendWebsiteFacebookDoctor's OfficeWICOtherAlternative Contact Name First Last Alternative Contact PhoneWhat is the best way to contact you?PhoneEmailYour Email Address When did you start seeing a doctor for your pregnancy? Within the first 12 weeks Weeks 13-27 After 28 weeks Is the father of your baby supportive/helpful?UnknownYesNoWill other family members be supportive/helpful?UnknownYesNoWill you have help at home after the baby arrives?UnknownYesNoDo you worry about where you will live after the baby is born?UnknownYesNoAre you working?UnknownYesNoIf you have a partner, does he/she work?UnknownYesNoAre you worried about how you are going to buy diapers and other things for your baby or other children?UnknownYesNoHave you completed high school?UnknownYesNoDid you use alcohol, marijuana, or other drugs before becoming pregnant?UnknownYesNoAre you concerned about you or your partner’s use of alcohol or drugs during your pregnancy?UnknownYesNoDo you feel stressed about your relationships or family lifeUnknownYesNoIn the past year, has there been a time lasting more than 2 weeks where you or your partner felt sad, hopeless, anxious, or depressed?UnknownYesNoDid you consider adoption or abortion during this pregnancy?UnknownYesNoAre you married to the father of your baby?UnknownYesNoWould you like to receive information about community resources for you and your baby?UnknownYesNoWould you like to receive information about parenting or child development?UnknownYesNoThis information will be shared with the California Home Visiting Program (California Department of Public Health), Shasta County HHSA, and Northern Valley Catholic Social Service. By initialing below, I agree to share this information with these organizations. Initial here:* CAPTCHA ALL STAFF2021-05-07T11:28:53-07:00
