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Mother Friendly Childbirth Initiative
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Families in Crisis Application
If you feel you are in need of a Labor or Postpartum doula, Childbirth Educator or Breastfeeding specialist but don't have the resources to afford one, please fill out our "Families in Crisis" Application below. All information is kept strictly confidential and is for the sole purpose of qualifying applicants.
Contact Information
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
How many children do you have?:
*
Your date of birth:
*
How did you hear of FIC?:
*
Daytime Phone Number
*
-
-
Evening Phone Number
*
-
-
Email
*
Are you a:
*
Teen Mother
Single Mother
Check all that apply.
Medical Information
Baby's due date:
*
Where are you giving birth? or have just given birth?:
*
Choose One
Nassau University Medical Center
North Shore Manhasset
Katz Women's
Southampton Hospital
South Nassau
Good Samaritan
Mercy Medical Center
Winthrop
Stonybrook University Hospital
St. Charles
Homebirth
Other
Not sure yet
Have you recently received a diagnosis of postpartum depression, post traumatic stress disorder or postpartum/antepartum anxiety disorder:
*
Has there been a sudden death of either the new mother or father/partner?
*
Have you or your partner been diagnosed with a sudden debilitating illness?
*
Do you have medical insurance? If yes, what is the name of the insurance company:
*
Financial Information
What is your combined household income?:
*
Can you provide proof of income?
*
Yes
No
Has your partner been or will he/she be deployed for military purposes?:
*
Yes
No
Are you receiving Alimony, Child Support?:
*
Are you receiving any other financial support?:
*
Have you or your partner recently been laid off?:
*
Yes
No
If so, how much severance are you being awarded?:
*
If applicable, how much is your unemployment?:
*
If applicable, how much is your disability?:
*
Are you receiving social services? WIC, Disability, Welfare, etc.:
*
How many homes do you own?:
*
What is your monthly mortgage/rental payment?:
*
How much do you have in savings?:
*
Please list other personal assets (boats, rv, etc.):
*
Amount of money you can apply towards services:
*
Are you seeking the support of:
*
Labor Doula
Postpartum Doula
Childbirth Education
Breastfeeding
check all that apply
Who else be accompanying you at the birth?:
*
How much money do you currently have in investments?:
*
What are your living arrangements? (live with parents, friends, spouse?):
*
Is there any other information you would like us to consider in regards to your request for assistance?:
*
Submit