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MOMcares Prenatal Outreach Program Interest Form

Caregiver Information

By providing your phone number, you agree to receive text messages from Linked Family Services.

Do you identify as female?
Yes
No
Mom Date of Birth
Month
Day
Year
Zip Code
Caregiver Ethnicity/Race (Select all that apply)
Preferred Contact Method
Are you currently pregnant or parenting a child less than 13 months old?

If no, you are not eligible for the program.

Child Information

Child Gender Identity
Male
Female
Prenatal/Unknown

If unborn, type "PRENATAL"

Child Ethnicity/Race (Select all that apply)

Program Participation

Do you have access to a smartphone or device for virtual check-ins?
Yes
No
Do you currently have Medical Assistance (Medicaid)?
Yes
No
Unsure

Family Needs

What support are you most interested in right now? (Check all that apply)
Do you have any current medical conditions that may impact your pregnancy or ability to care for your child? (Check all that apply)
Are you experiencing any of the following challenges? (Check all that apply)
Do you or your child have a diagnosed or suspected developmental delay, disability, or cognitive challenge?
Have you been told this is a high-risk pregnancy?
Yes
No
Not Sure
Have you ever received early intervention services, behavioral health services, or developmental screenings for yourself or your child?
Yes
No
Not Sure
Are you currently receiving WIC, Early Head Start, or home visiting services?
Are you currently connected to any other support programs or case managers?
Yes
No
Do you have a doula?
Yes
No
How did you hear about Walk With Me: The MotherRoot Project?

Consent

I give permission for Linked Family Services to take and use photos of me and/or my child(ren) for program documentation, promotional materials, or social media.
Yes
No
Do you give permission for Linked Family Services to bill Medical Assistance (Medicaid) or your managed care organization for eligible care coordination services provided to you through the MOMcares Prenatal Outreach Program?
Yes, I consent
No, I do not consent
I understand that my information may be shared with my health plan or Medicaid provider for the purpose of verifying eligibility, coordinating services, and submitting billing claims related to my participation in this program.
I understand and agree
I understand that my participation in the MOMcares Prenatal Outreach Program is voluntary, and I may withdraw consent to share my information or be billed for at any time.
I understand and agree
I understand that my participation in the MOMcares Prenatal Outreach Program is voluntary, and I may withdraw consent to share my information or be billed for at any time.
I understand and agree

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