0-36 Months Materials Assistance

0-36 Months Materials Assistance Form

I am a:(Required)

New client

Returning client

Have you registered with Care Net of Central Texas before?

Event City(Required)

Mexia (Sep 26th)

Killeen (Oct 3rd) – Limited Spots Remaining

Hillsboro (Oct 17th)

We host this event in various cities. Select all you’d like to be notified about! (You don’t have to live there)

Today's Date(Required)

Month

Day

Year

Date of birth of your youngest child?(Required)

Month

Day

Year

Was your youngest chld's birth weight less than 5 lbs. 8 oz.?(Required)

Yes

Was your youngest child born preterm (before 37 weeks)?(Required)

Yes

Do you have any children 1 day or older? If so, please tell us about them.(Required)

List each child’s date of birth and sex on one line.

Are you a U.S. citizen or eligible for Medicaid?(Required)

Yes

Do you have access to a device for virtual meetings (Zoom)?

Yes

Other

If you attend one of the two amazing pregnancy/parenting classes we send you, you’ll be qualified to come and pick up your items!

Name(Required)

First Last

Your Date of birth(Required)

Month

Day

Year

Zip Code(Required)

Phone(Required)

Email(Required)

Where are you located?(Required)

What city, or general area?

Sex(Required)

Male

Female

Marital Status(Required)

Married

Single

Highest education completed

Less than high school

Some high school

High school degree or GED

Some college

College degree

Some post-graduate

Post-graduate degree

Ethnicity

Black (non-Hispanic)

Hispanic

White (non-HIspanic)

Asian or Pacific-Islander

American Indian/Alaska Native

What size of diapers, baby clothes, and type of formula (if applicable) do you need?

For example: Size 3 diapers, 6-9 mo boy clothes, Infamil Gentlease

SPIRITUAL PREFERENCE

Among the many services we can provide you, some can help you with your spiritual health. For example, if you find comfort in prayer, someone here can pray with you, if you’d like. We offer spiritual services because they’re a part of our faith background. However, we will not offer to provide you spiritual services if you don’t want us to. All of the other services we provide are still here for you, even if you decide not to receive spiritual help. If you are open to receiving spiritual services, I will introduce you to another counselor here who will provide these services to you. And, if you prefer not to receive any services – spiritual or otherwise – from us, we will help you find another provider of your choice. Please check your preference below(Required)

Yes, it is okay with me if you offer me spiritual help during my time here.

No, thank you, but at this time I do not want you to offer me any spiritual services.

How did you hear about this event?

I got a text/email

Facebook/Instagram

I saw a flier

A friend shared it with me

I knew about Care Net before

PRCs are a great place for anyone struggling with an unexpected pregnancy. They provide accurate information, non-judgmental care and material assistance for those choosing to parent. They provide information on your options so you can make an informed choice. Keep up the good work!

Good place with good people.

Amazing staff! They were so helpful during my pregnancy!

Thank you to all the staff for everything they do . Has helped me become mommy ready and providing a supportive welcoming environment.

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