Bellies to Babies Welcome Card

Please provide us with the following confidential information.

Date

Name

Your Date of Birth

Partner’s Name or Primary Support

Phone (H)

Phone (C)

Is it okay to leave messages?

Yes

No

Is it okay to text you?

Yes

No

Email

If you wish to receive weekly drop-in notices

Address

City

State/Province

Zip/Postal

Country

Physician/Midwife

If you are Pregnant

When is Baby due

Weeks Gestation

Is this your first pregnancy?

Yes

No

If you are not Pregnant

When was your Baby Born

Baby’s Name

Birth Weight

Sex of the Baby

Boy

Girl

What encouraged you to come to Bellies to Babies? (please check all that apply)

To learn about healthy pregnancies & caring for your baby

To learn about breastfeeding

To obtain access to a healthcare professional (nurse)

Prenatal Education

To meet other parents

To get food, food vouchers

Was referred by health care professional ( ie. nurse, doctor)

To learn about healthy eating

OtherOther

A weekly food voucher is available to participants who identify as having financial challenges to obtaining adequate, nutritious food. Are you interested in more info on the Food Voucher Program?

Yes

No

Bellies to Babies offers health education/information & breastfeeding support by a Registered Nurse/IBCLC, and outreach support by a family support worker. The program is available to anyone during pregnancy and throughout the first 12 months postpartum. Program staff are also available to visit 1:1 upon request.

What questions do you have for us at this time, if any?

Bellies to Babies Consent for Services

Bellies to Babies uses a multi-disciplinary model of support, which includes community partners, to provide comprehensive services and ensure ease of access to appropriate services. Your consent is needed for the followings.

I authorize Bellies to Babies to collect, use, and release information with the following people and/or agencies for the purposes of providing appropriate assessment and services to myself and/or my newborn child:
- My Physician/Midwife
- Interior Health (Public Health Nurse, IDP, PT, OT, MH, Diabetes Education)
- Fernie Women’s Resource Centre (Sponsoring Agency)
I understand the services being offered to me and I choose to participate in Bellies to Babies program.
I understand that this is a voluntary program and I can choose to withdraw at any time.
I understand that Bellies to Babies will disclose information where the law requires: ie: court order; when there is suspicion of child abuse; and other instances where you may pose a threat of serious injury to yourself or others.)
I understand that data, without my name or anything to identify me or my family, will be used for research, statistics, and program reports.

Consent

I have read and agreed to the Bellies to Babies Consent for Services

Participant Name

Date

Bellies to Babies Group Expectations

Bellies to Babies has weekly group drop-ins. We ask you respect the following:

Sensitive subjects may arise during drop-in. Please practice self-care. If needed, take time for yourself or speak to a group facilitator after drop-in.
Facilitators treat all information shared by participants as confidential. Be mindful that when sharing in a group space confidentiality cannot be guaranteed.
Given that, information shared by participants at drop-ins should stay in the room. Respect others.
Honour every mothers’ unique and individual experience of pregnancy and motherhood. Individuals bring different knowledge and experiences to the group.