The SisterFriends Project: Pregnant Mom (Little Sister) Enrollment Form
The SisterFriends Project: Little Sister Enrollment Form
Is this a Make Your Date Referral?
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Cell/Personal Telephone Number
Alternative Phone Number:
Can you receive texts?
Best time of day to call
Date of Birth
How many weeks pregnant are you?
When is your due date?
I Could Use Help With? (Check all that apply)
A Doctor/ Midwife for My Pregnancy
Pregnancy Education Classes
Women, Infants, Children’s (WIC) Nutrition Program
What type of things would you like to do with your SisterFriend?
Attend childbirth education classes
Do a tour of the hospital your Little Sister will give birth at
Go to dinner
Talk on the phone
Go to church
Go to the movies
Attend a parenting class
How do you feel a SisterFriend can assist you in your pregnancy journey?
Providing emotional support
Assisting you with educational goals
Attending childbirth classes
Linking you to services that you may need
Helping you stay organized around your pregnancy
Helping you figure out your goals after pregnancy
Accompanying you to your delivery
Linking you to child care resources
Do you have a preference for the age of your SisterFriend?
It doesn't matter what age she is.
Does your home have any of the following?
Are any of the following a concern in your home?
Do you smoke currently?
Do you have other children?
If you do have other children, how many?
If you do have other children, how old are they?
How many times have you been pregnant? (including this pregnancy)
How recent was your last pregnancy?
Is there anything else we need to know to make the best SisterFriend match for you?
What type of Social Media do you use (if any)? (Mark all that apply)
Social Media (other)
What is your race?
American Indian or Native Alaskan
What is your ethnicity?
Hispanic or Latino
NOT Hispanic or Latino
What are some of your goals?
What are some of your biggest challenges?
Biggest Challenges (other)
What things do you do for fun?
What are some of your strengths?
What are you looking for in your SisterFriend?
Is the father of your baby involved?
Name of Support Person
Role of support person (please check all that apply):
Father of baby
Would you like us to reach out to, and share SisterFriends resources and event information, with your support person?
Support person's phone number
Support person's email
How can we reach your support person?
Provider's Phone Number
Hospital You Plan To Deliver At
Are you currently enrolled in WIC?
What type of insurance do you have?
Private (through employer, through health care marketplace/exchange)
Do you currently have a primary care doctor?
Current Primary Care Provider (non-OB/GYN)
Do you currently have a prenatal care provider?
When did you start receiving your prenatal care?
First 3 months
Do you currently have a dentist?
Do you currently have a pediatrician?
Do you have transportation?
What type of transportation do you primarily use?
Car Service (ex. Uber, Lyft)
I do not have transportation
Are you currently enrolled in Medicaid?
Do you currently have a medical home (a primary care doctor, a dentist, pediatrician)?
First Day of Last Menstrual Period
Last Method of Birth Control
Do you plan on breastfeeding?
Do You Have a History of Preterm Birth?
Do You Have a History of Pre-eclampsia?
List 3 positive things about you:
Anything else you would like to share:
My challenges or limitations:
I Prefer to be Contacted by
How did you hear about SisterFriends?
Make Your Date
Detroit Medical Center
Henry Ford Hospital
St. John's Hospital
I give the Detroit Health Department permission to collect and share data contained in this application. I also give permission for the Detroit Health Department to contact me by phone/email regarding the information contained in this form.
If you do not agree to sharing your information with the Detroit Health Department, you cannot enroll at this time. To learn more about joining SisterFriends, call 313.961.BABY or email email@example.com
I give Make Your Date permission to collect and share the data contained in this application. I also give Make Your Date permission to contact me by phone/email regarding the information contained in this form.
You can decide whether or not to also share your information with Make Your Date
, a partner organization, in addition to the Detroit Health Department.
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