0-36 Months Materials Assistance

0-36 Months Materials Assistance Form

I am a:

New Client

Returning Client

Diaper Dash Event Date(Required)

Today's Date

Name(Required)

First Last

Date of birth(Required)

Zip Code

Phone(Required)

Email(Required)

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

Yes

Where are you located?

Sex

Male

Female

Marital Status

Married

Single

Date of birth of your youngest child?

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

Yes

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

Yes

Number of other children who are 1 day or older?

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

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

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

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

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.

0-36 Months Materials Assistance Form

SPIRITUAL PREFERENCE

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Live bravely. Strength becomes you.