Maternal and Child Health Access
Parent Coach:
Welcome Baby
Prenatal Intake
Postpartum Intake
Date:
Start time:
Client ID #:
DOB:
Hospital Liaison:
Supervisor:
LMP:
EDD:
Weeks of gestation:
Client Characteristics Mom/Client name: Home address: Home phone number:
Mobile phone number:
Additional (e-mail): 1. Relationship to newborn? Biological parent
Step-parent/ Parent’s partner
Grandparent
Adoptive parent
Other:
Single
Married
Separated
Divorced
Widowed
Living together/ Common law
Other:
2. Marital status:
3. Born in the U.S.?
Yes
If no, country of birth:
5. Primary language: Spanish
Declined to respond
If no, how many years in the U.S.?
4. Race/Ethnicity:
English
No
Other:
Education & Employment 1. Highest grade completed: None
Elementary School (1-6 grade)
Middle/Jr. High School (7-9 grade)
High School (1012 grade, did not graduate)
High School Graduate
Vocational School
GED
Some College
Associates Degree
Bachelors Degree or Higher
2. Currently employed?
Yes
No
Unknown
If yes, employment type: Full-time
Part-time
Self-employed
Temporary
3. Which of the following categories best describes your total household income in the last 12 months? Less than $10,000
$10,000-$19,999
$20,000-$29,999
$30,000-$39,999
$50,000-$74,999
$75,000 or more
Do not know
Declined to respond
$40,000-$49,999
Health Care and Public Benefits 1. Are you covered by any of the following health insurance programs? Medi-Cal Presumptive Eligibility
Restricted MediCal
Medi-Cal Managed Care
Full-Scope MediCal
Healthy Families
Healthy Kids
AIM
No health insurance
Private health insurance:
Other:
2. Do you have dental insurance?
Yes
No
3. Have you received a dental exam in the last 12 months?
Yes
No
4. Do you have a medical provider?
Yes
No
Providers name:
Clinic’s name:
Address: City:
Phone number:
5. Is your family receiving any of the following benefits? CalWORKs
Food Stamps
Homeless Assistance
WIC
General Relief
Other:
None
Declined to respond
SSI/SSD
****If needed, please make referral****
Other Children in Household Name:
Age at intake:
Name:
Age at intake:
Name:
Age at intake:
Secondary Caregiver Information Name:
Sex:
1. Relationship to newborn? Biological parent
Step-parent/ Parent’s partner
Grandparent
2. Currently employed?
Yes
Adoptive parent
Other:
No
If yes, employment type: Full-time
Part-time
Self-employed
Temporary
Don’t know
Best Start LA Community Utilization Data 1. How long have you lived in the neighborhood?
Less than 1 year
1-3 years
2. In the last 6 months, have you visited a local park?
Yes
No
3. In the last 6 months, have you visited a local library?
Yes
No
4. In the last 6 months, have you participated in an event that provided parenting education and/or support? 5. Does your family feel close to other families in the neighborhood?
Yes
No
Yes
No
3+ years
6. Do your family members support each other when things are stressful? End Time: ____:_____
Rev. 12/16/10
Yes
No
Total length of visit: ________ minutes
Maternal and Child Health Access
Parent Coach:
Welcome Baby
Pregnancy Information (up to 27 weeks) Date:
Start time:
LMP:
EDD:
Client ID #:
Supervisor:
Visit Information Attempted visit #1:
Attempted visit #2:
Attempted visit #3:
Changes in address or phone #: Mom/Client name: 1. Location of Visit: Participant’s home
Medical provider office
WIC office
Home visiting office
Other: ______________
Grandparent
Siblings
Supervisor (observation)
2. Who participated in this home visit? Mother/Client Other: ______________
Secondary caregiver/Father
Health Care 1. Dental Status Client received an exam in the last 12 months.
Client has scheduled an appointment for a dental exam.
Dental referral made by WB.
Client received a referral from elsewhere.
Client opts out of dental services.
Breastfeeding Intent 1. How do you plan to feed your baby? Breast only
Breast and formula
Formula only
If you intend on breastfeeding, how long do you plan on breastfeeding (in months)? ______________ 2. Breastfeeding education or support provided? ****If needed, please make referral****
Yes
No
Social Support and Involvement of Father/Secondary Caregiver 1. Is the father of the baby supportive of the pregnancy?
Yes
No
N/A
Declined to state
2. Are your friends supportive of the pregnancy?
Yes
No
N/A
Declined to state
3. Is your family supportive of the pregnancy?
Yes
No
N/A
Declined to state
4. Are you able to see your family often?
Yes
No
N/A
Declined to state
****If needed, please make referral****
Depression 1. Depression screening PHQ-2 completed?
Yes
No
2. Did the client respond “yes” to at least one question on PHQ-2?
Yes
No
Yes
No
Yes
No
If yes, complete PHQ-9 3. PHQ-9 completed? If yes, score: ****If depression present, please make referral****
Risk Categories 1. Did client discuss or have any of the following? Homelessness
Domestic Violence
Depression (>10 PHQ9)
Mental Illness
Substance Abuse
Infant in NICU
Hospitalization Beyond 48-72 Hours
Child Abuse
Medical Infant
Medical Mother
Infant Delay
None
Other: ______________
DCFS Case
Extreme Financial Hardship
(shelter, motel, care, in temporary living)
End Time: ____:_____ Rev. 8/1/12
Specify:
Trauma/History of
Specify:
Teen
Total length of visit: ________ minutes
Maternal and Child Health Access
Parent Coach:
Welcome Baby
Pregnancy Information: Call at 20-32 weeks Date:
Start time:
LMP:
EDD:
Client ID #:
Supervisor:
Visit Information Changes in address or phone #: Mom/Client name:
Prenatal Testing 1. Have you received a glucose screening test?
Yes
No
If yes, what were the results? Not at risk for GDM
Required followup test
Don’t know
2. If follow-up test was performed, what were the results? Positive for GDM
Negative for GDM
Don’t know
3. Have you received your AFP/triple screen test?
Yes
No
Don’t know
If yes, what were the results? Positive/At risk
Negative/Low risk
Don’t know
Health Care 1. Dental Status Client received an exam in the last 12 months.
Client has scheduled an appointment for a dental exam.
2. Have you changed providers? If yes, new provider:
Dental referral made by WB.
Yes
Client received a referral from elsewhere. No
Client opts out of dental services.
3. Have there been any changes in your health insurance?
Yes
No
If yes, changed to: Medi-Cal Presumptive Eligibility
Restricted Medi-Cal
Medi-Cal Managed Care
Full-Scope Medi-Cal
Healthy Families
Healthy Kids
AIM
No health insurance
Private health insurance: ______________
Other: ______________
****If needed, please make referral****
Depression 1. Depression screening PHQ-2 completed?
Yes
No
2. Did the client respond “yes” to at least one question on PHQ-2?
Yes
No
Yes
No
If yes, complete PHQ-9 3. PHQ-9 completed? If yes, score: ****If depression present, please make referral**** End Time: ____:_____
Rev. 6/6/12
Total length of visit: ________ minutes
Maternal and Child Health Access
Parent Coach:
Welcome Baby
Pregnancy Information (28-38 weeks) Date:
Start time:
LMP:
EDD:
Client ID #:
Supervisor:
Visit Information Attempted visit #1:
Attempted visit #2:
Attempted visit #3:
Changes in address or phone #: Mom/Client name: 1. Location of Visit: Participant’s home
Medical provider office
WIC office
Home visiting office
Other: ______________
Grandparent
Siblings
Supervisor (observation)
2. Who participated in this home visit? Mother/Client
Secondary Caregiver/Father
Other: ______________
Health Care 1. Dental Status Client received an exam in the last 12 months.
Client has scheduled an appointment for a dental exam.
Dental referral made by WB.
Client received a referral from elsewhere.
(Skip these questions if this is client’s first visit) 2. Have you changed providers?
Yes
No
Don't know
Yes
No
Don't know
If yes, new medical provider: 3. Have there been any changes in your health insurance?
Client opts out of dental services.
If yes, changed to: Medi-Cal Presumptive Eligibility
Restricted Medi-Cal
Medi-Cal Managed Care
Full-Scope Medi-Cal
Healthy Families
Healthy Kids
AIM
No health insurance
Private health insurance: ______________
Other:
****If needed, please make referral****
______________
Breastfeeding Intent 1. How do you plan to feed your baby? Breast only
Breast and formula
Formula only
If you intend on breastfeeding, how long do you plan to breastfeed (in months)? ___________ 2. Breastfeeding education or support provided?
Yes
No
****If needed, please make referral****
Home Safety 1. Does anyone smoke in the home?
Yes
No
N/A
Declined to state
2. Do you have working smoke detectors?
Yes
No
N/A
Declined to state
3. Do you have a car seat for the baby?
Yes
No
N/A
Declined to state
4. Are there any broken windows in your home?
Yes
No
N/A
Declined to state
5. Are there any missing screens in your home?
Yes
No
N/A
Declined to state
6. Do you have a working heater?
Yes
No
N/A
Declined to state
7. Is there a possible exposure to lead due to peeling or chipped paint (in home built prior to 1978)?
Yes
No
N/A
Declined to state
8. Does anyone in the home work at a job that exposes them to lead, pesticides or other contaminants?
Yes
No
N/A
Declined to state
9. Is there mold in the home?
Yes
No
N/A
Declined to state
10. Are there cockroaches or rodents in the home (by observation or report)?
Yes
No
N/A
Declined to state
11. Education provided on the following: (check all that apply) Lead
Second-hand smoking
Sleeping arrangements
Car seat safety
Smoke detectors
Other: ______________ ****If needed, please make referral****
Social Support and Involvement of Father/Secondary Caregiver
1. Is the father of the baby supportive of the pregnancy?
Yes
No
N/A
Declined to state
2. Is your family supportive of the pregnancy?
Yes
No
N/A
Declined to state
****If needed, please make referral****
Depression 1. Depression screening PHQ-2 completed?
Yes
No
2. Did the client respond “yes” to at least one question on PHQ-2?
Yes
No
Yes
No
If yes, complete PHQ-9 3. PHQ-9 completed? If yes, score: ****If depression present, please make referral****
Risk Categories 1. Did client discuss or have any of the following? Homelessness
Domestic Violence
Depression (>10 PHQ9)
Mental Illness
Substance Abuse
Infant in NICU
Hospitalization Beyond 48-72 Hours
Child Abuse
Medical Infant
Medical Mother
Infant Delay
None
Other: ______________
DCFS Case
Extreme Financial Hardship
(shelter, motel, care, in temporary living)
End Time: ____:_____ Rev. 8/1/12
Specify:
Trauma/History of
Specify:
Teen
Total length of visit: ________ minutes
Maternal and Child Health Access
Parent Coach:
Welcome Baby
Postpartum Hospital Visit Date:
Start time:
Client ID #:
Supervisor:
LMP:
EDD:
Hospital Liaison:
Visit Information Attempted visit #1:
Attempted visit #2:
Attempted visit #3:
Changes in address or phone #: Mom/Client name: Date of delivery:
Expected date of discharge:
1. Who participated in this visit? Mother/Client Other:
Secondary caregiver/Father
Grandparent
2. Was newborn present?
Siblings
Yes
No
Yes
No
2. Have you scheduled an appointment for your postpartum check-up?
Yes
No
3. Have you scheduled an appointment for the 2 week well-baby check-up?
Yes
No
If not, why?
Health Care 1. Have you changed providers? (Skip this question if this is first visit/intake) If yes, new medical provider:
****If needed, please make referral****
Supervisor (observation)
Breastfeeding 1. How are you feeding your baby? Breast only
Mostly breast, with some formula
Mostly formula, with some breast
Formula
Other:
5 - 6 months
7 - 9 months
2. (If breastfeeding) How long would you like to breastfeed? About 1 month or less
About 6 weeks 2 months
10 - 12 months
12+ months
3 - 4 months
3. Were you helped and encouraged to hold your newborn skin-to-skin after delivery and at other times? (Check all that apply) Yes, within the first hour after delivery
Yes, the first day
After the first day
Not at all
N/A
4. Were you given the opportunity to have roomingin with your baby? (Rooming-in is defined as 23 out of 24 hours per day from birth to discharge)
Yes
No
N/A
5. Breastfeeding education or support provided?
Yes
No
N/A
6. Breastfeeding assistance provided?
Yes
No
N/A
If yes, what type: (check all that apply) Latch-on & positioning
Pumping
Engorgement
Sore nipples
Milk supply
****If needed, please make referral****
Social Support and Involvement of Father/Secondary Caregiver 1. Do you have someone to help you with baby?
Yes
No
2. Was the father/secondary caregiver with you during the birth?
Yes
No
****If needed, please make referral****
Parent Infant Interaction Observation 1. Was positive mother/infant interaction observed?
Yes
No
N/A
2. Does mother look and smile at infant frequently?
Yes
No
N/A
3. Does mother have positive observations about baby?
Yes
No
N/A
4. Does mother touch, massage or gently rub baby?
Yes
No
N/A
1. Depression screening PHQ-2 completed?
Yes
No
2. Did the client respond “yes” to at least one question on PHQ-2?
Yes
No
Yes
No
****If needed, please make referral****
Depression
If yes, complete PHQ-9 3. PHQ-9 completed? If yes, score: ****If depression present, please make referral****
Risk Categories 1. Did client discuss or have any of the following? Homelessness
Domestic Violence
Depression (>10 PHQ9)
Mental Illness
Substance Abuse
Infant in NICU
Hospitalization Beyond 48-72 Hours
Child Abuse
Medical Infant
Medical Mother
Infant Delay
None
Other: ______________
DCFS Case
Extreme Financial Hardship
(shelter, motel, care, in temporary living)
End Time: ____:_____
Rev. 8/1/12
Specify:
Trauma/History of
Specify:
Teen
Total length of visit: ________ minutes
Maternal and Child Health Access
Parent Coach:
Welcome Baby Newborn Intake
Date:
Start time:
Client ID #:
Hospital Liaison:
Supervisor:
Newborn Information Newborn's name:
Date of birth:
Newborn's sex?
Male
Female
Mom/Client name:
Prenatal Care and Pregnancy Outcomes 1. Approximate date mom began to receive prenatal care: 2. Did mom smoke during this pregnancy?
Yes
No
3. Type of delivery? Vaginal
C-Section
4. Any birth complications? 5. Gestational age? Full term
weeks
6. Birthweight:
Premature weeks (lbs)
7. Length:
(oz)
8. Was newborn in the intensive care nursery?
Yes
No
If yes, reason:
Health Care 1. Will the newborn be covered by any of the following? Medi-Cal Other
Healthy Families
Healthy Kids
Private health insurance:
No health insurance
2. Was the newborn referral form faxed?
Yes
No
Yes
No
If yes, date: 3. Does the newborn have a medical provider?
Don't know
If yes, Doctor's name and facility: Address: Phone: ****If needed, please make referral**** End Time: ____:_____
Rev. 9/14/10
Total length of visit: ________ minutes
Maternal and Child Health Access
RN:
Welcome Baby
Postpartum: 72 Hour Nurse Visit Date:
Start time:
Client ID #:
Supervisor:
P.C.:
Visit Information Attempted visit #1:
Attempted visit #2:
Attempted visit #3:
Changes in address or phone #: Mom/Client name:
Baby’s name:
1. Location of Visit: Participant’s home
Medical provider office
WIC office
Home visiting office
Other: ______________
Grandparent
Siblings
Supervisor (observation)
2. Who participated in this home visit? Mother/Client
Secondary caregiver/Father
Other: ______________ 3. Was newborn present?
Yes
No
Yes
No
If no, why? 4. Is your baby in the NICU?
Health Care 1. Have you scheduled an appointment for your postpartum check-up?
Yes
No
2. Have you scheduled an appointment for the first well-baby checkup?
Yes
No
N/A in NICU
3. If provider was not chosen previously, does the newborn now have a medical provider?
Yes
No
N/A in NICU
If yes, medical provider: ****If needed, please make referral****
Maternal Assessment Key: √ = WNL * = needs follow-up 1. Discharge date: 2. Perinatal screening: Cramping
Clots
Lochia
Urine
Bowel
Hemorrhoids
Perineum
C/S incision
Formula only
Other:
3. Pertinent hospital information: 4. If needed: Temp:
B/P:
Fundus:
Notes:
Breastfeeding 1. How are you feeding your baby? (check all that apply) Breast only
Mostly breast, with some formula
Mostly formula, with some breast
2. Breastfeeding education or support provided?
Yes
No
3. Breastfeeding assistance provided?
Yes
No
N/A in NICU
If yes, what type: (check all that apply) Latch-on & Positioning
Pumping
Engorgement
Sore nipples
Milk supply
4. If client stopped breastfeeding, please check the reasons for this: (check all that apply) Not enough milk
Sore or cracked nipples
Pain
Latch-on difficulties
Medical reason
Return to work
Medication
Lack of support from partner
Lack of support from family
Other:
5. How long did you breastfeed? ****If needed, please make referral****
days
Newborn Assessment Key: √ = WNL * = needs follow-up Fontanelles
Heart
Lungs
Abdomen
Umbilicus
Circumcision
Skin tugor
Tone
Reflexes
Stools
Void
Cry
Temp:
Weight:
Notes:
****If needed, please make referral****
Home Safety Assessment (if baby in NICU, skip) 1. Are there safe sleeping arrangements for the baby?
Yes
No
N/A in NICU
2. Do you have a car seat for the baby?
Yes
No
N/A in NICU
3. Does anyone smoke in the home?
Yes
No
N/A in NICU
4. Was a home safety item given?
Yes
No
N/A in NICU
5. Has the family made a home safety improvement and/or childproofed the home?
Yes
No
N/A in NICU
If other, please specify: 6. Education provided on the following? (Check all that apply) Lead
Second-hand smoking
Sleeping arrangements
Car seat safety
Smoke detectors
Other: ______________ ****If needed, please make referral****
Social Support and Involvement of Father/Secondary Caregiver 1. Do you have someone to help you with daily chores?
Yes
No
N/A
Declined to state
2. Do you have someone to help you with other children? 3. Do you have help with caring for the baby from the father/secondary caregiver?
Yes
No
N/A
Yes
No
N/A
Declined to state Declined to state
4. Do you have someone you can count on to listen to you when you need to talk?
Yes
No
N/A
Declined to state
****If needed, please make referral****
Parent-Infant Interaction Observation 1. Was positive mother/infant interaction observed?
Yes
No
N/A in NICU
2. Does mother look and smile at infant frequently?
Yes
No
N/A in NICU
3. Does mother have positive observations about baby?
Yes
No
N/A in NICU
4. Does mother touch, massage or gently rub baby?
Yes
No
N/A in NICU
****If needed, please make referral****
Depression 1. Depression screening PHQ-2 completed?
Yes
No
2. Did the client respond “yes” to at least one question on PHQ-2?
Yes
No
Yes
No
If yes, complete PHQ-9 3. PHQ-9 completed? If yes, score: ****If depression present, please make referral****
Risk Categories 1. Did client discuss or have any of the following? 2.
Homelessness
Domestic Violence
Depression (>10 PHQ9)
Mental Illness
Substance Abuse
Infant in NICU
Hospitalization Beyond 48-72 Hours
Child Abuse
Medical Infant
Medical Mother
Infant Delay
None
Other: ______________
DCFS Case
Extreme Financial Hardship
(shelter, motel, care, in temporary living)
End Time: ____:_____ Rev. 8/1/12
Specify:
Trauma/History of
Specify:
Teen
Total length of visit: ________ minutes
Maternal and Child Health Access
RN:
Welcome Baby
Postpartum: 72 Hour Nurse Visit - NICU Date:
Start time:
Client ID #:
Supervisor:
P.C.:
Visit Information Attempted visit #1:
Attempted visit #2:
Attempted visit #3:
Changes in address or phone #: Mom/Client name:
Baby’s name:
1. Location of Visit: Participant’s home
Medical provider office
WIC office
Home visiting office
Other: ______________
Grandparent
Siblings
Supervisor (observation)
2. Who participated in this home visit? Mother/Client
Secondary caregiver/Father
Other: ______________ 3. Was newborn present?
Yes
No
If no, why?
Health Care 1. Have you scheduled an appointment for the first well-baby checkup?
Yes
No
2. Does the newborn now have a medical provider?
Yes
No
Yes
No
If yes, medical provider: 3. Have you scheduled an appointment for your postpartum check-up? ****If needed, please make referral****
Breastfeeding 1. How are you feeding your baby? (check all that apply) Breast only
Mostly breast, with some formula
Mostly formula, with some breast
Formula
2. Breastfeeding education or support provided?
Yes
No
3. Breastfeeding assistance provided?
Yes
No
Other:
If yes, what type: (check all that apply) Latch-on & positioning
Pumping
Engorgement
Sore nipples
Milk supply
4. If client stopped breastfeeding, please check the reasons for this: (check all that apply) Not enough milk
Sore or cracked nipples
Pain
Latch-on difficulties
Medical reason
Return to work
Medication
Lack of support from partner
Lack of support from family
Other:
5. How long did you breastfeed?
days
****If needed, please make referral****
Newborn Assessment Key: √ = WNL * = needs follow-up Fontanelles
Heart
Lungs
Abdomen
Umbilicus
Circumcision
Skin tugor
Tone
Reflexes
Stools
Void
Cry
Temp:
Weight:
Update on Baby’s Condition/Notes:
****If needed, please make referral****
Home Safety Assessment 1. Are there safe sleeping arrangements for the baby?
Yes
No
2. Do you have a car seat for the baby?
Yes
No
3. Does anyone smoke in the home?
Yes
No
4. Was a home safety item given?
Yes
No
N/A
5. Has the family made a home safety improvement and/or childproofed the home?
Yes
No
N/A
If other, please specify: 6. Education provided on the following? (Check all that apply) Sleeping arrangements
Car seat safety
Second-hand smoking
Smoke detectors
Lead
Other: ______________ ****If needed, please make referral****
Social Support and Involvement of Father/Secondary Caregiver 1. Do you have someone to help you with daily chores?
Yes
No
N/A
Declined to state
2. Do you have someone to help you with other children?
Yes
No
N/A
Declined to state
3. Do you have help with caring for the baby from the father/secondary caregiver?
Yes
No
N/A
Declined to state
4. Do you have someone you can count on to listen to you when you need to talk?
Yes
No
N/A
Declined to state
****If needed, please make referral****
Parent-Infant Interaction Observation 1. Was positive mother/infant interaction observed?
Yes
No
N/A
2. Does mother look and smile at infant frequently?
Yes
No
N/A
3. Does mother have positive observations about baby?
Yes
No
N/A
4. Does mother touch, massage or gently rub baby?
Yes
No
N/A
****If needed, please make referral****
Depression 1. Depression screening PHQ-2 completed?
Yes
No
2. Did the client respond “yes” to at least one question on PHQ-2?
Yes
No
Yes
No
If yes, complete PHQ-9 3. PHQ-9 completed? If yes, score: ****If depression present, please make referral****
Risk Categories 1. Did client discuss or have any of the following? 2.
Homelessness
Domestic Violence
Depression (>10 PHQ9)
Mental Illness
Substance Abuse
Infant in NICU
Hospitalization Beyond 48-72 Hours
Child Abuse
Medical Infant
Medical Mother
Infant Delay
None
Other: ______________
DCFS Case
Extreme Financial Hardship
(shelter, motel, care, in temporary living)
End Time: ____:_____
Rev. 8/1/12
Specify:
Trauma/History of
Specify:
Teen
Total length of visit: ________ minutes
Maternal and Child Health Access
Parent Coach:
Welcome Baby
Postpartum: 2-4 week visit Date:
Start time:
Client ID #:
Supervisor:
Visit Information Attempted visit #1:
Attempted visit #2:
Attempted visit #3:
Changes in address or phone #: Mom/Client name: 1. Location of Visit: Participant’s home
Medical provider office
WIC office
Home visiting office
Other: ______________
Grandparent
Siblings
Supervisor (observation)
2. Who participated in this home visit? Mother/Client
Secondary caregiver/Father
Other: ______________ 3. Was infant present?
Yes
No
If no, why?
Health Care and Public Benefits 1. Do you still have health insurance?
Yes
No
If yes, check all that apply Medi-Cal Presumptive Eligibility
Restricted Medi-Cal
Medi-Cal Managed Care
Full-Scope Medi-Cal
Healthy Families
Healthy Kids
AIM
No health insurance
Private health insurance: ______________
Other: ______________
2. Have you changed providers?
Yes
No
Yes
No
4. Was information on local food resources provided (WIC, Farmers' Markets, etc.)?
Yes
No
5. Were options on emergency and/or ongoing care given?
Yes
No
6. Has the baby received his/her health insurance card?
Yes
No
7. Have you changed the infant's medical provider?
Yes
No
8. Have you scheduled the first well-baby check up?
Yes
No
9. Have you attended the first well-baby check up?
Yes
No
10. Do you have your infant's immunization record?
Yes
No
11. Has your infant received the recommended immunizations for their age?
Yes
No
12. Have there been any changes in need for public benefits?
Yes
No
If yes, new provider: 3. Have you scheduled your postpartum check-up? If yes, date:
If yes, new provider:
****If needed, please make referral****
Breastfeeding 1. How are you feeding your baby? Breast only Mostly breast, with some formula
Mostly formula, with some breast
Formula
2. Breastfeeding education or support provided?
Yes
No
3. Breastfeeding assistance provided?
Yes
No
Other:
If yes, what type: (check all that apply) Latch-on & positioning
Pumping
Engorgement
Sore nipples
Milk supply
4. If client stopped breastfeeding, please check the reasons for this: (check all that apply) Not enough milk
Sore or cracked nipples
Pain
Latch-on difficulties
Medical reason
Return to work
Medication
Lack of support from partner
Lack of support from family
Other:
5. How long did you breastfeed?
days
weeks
months
****If needed, please make referral****
Home Safety Assessment 1. Does anyone smoke in the home?
Yes
No
2. Do you have working smoke detectors?
Yes
No
3. Are there any broken windows in your home?
Yes
No
4. Are there any missing screens in your home?
Yes
No
5. Do you have a working heater?
Yes
No
6. Is there a possible exposure to lead due to peeling or chipped paint (in home built prior to 1978)?
Yes
No
7. Does anyone in the home work at a job that exposes them to lead, pesticides or other contaminants?
Yes
No
8. Is there mold in the home?
Yes
No
9. Are there cockroaches or rodents in the home (by observation or report)?
Yes
No
10. Was a home safety item given?
Yes
No
N/A
11. Has the family made a home safety improvement and/or childproofed the home?
Yes
No
N/A
If yes, please specify: 12. Education provided on the following: (check all that apply) Lead
Second-hand smoking
Other: ______________ ****If needed, please make referral****
Sleeping arrangements
Car seat safety
Smoke detectors
Social Support and Involvement of Father/Secondary Caregiver 1. Do you have someone to help you with chores?
Yes
No
N/A
2. Do you have someone to help you with other children?
Yes
No
N/A
3. Do you have help with caring for the baby from the father/secondary caregiver?
Yes
No
N/A
Declined to state
4. Do you have someone who shows you love and affection?
Yes
No
N/A
Declined to state
****If needed, please make referral****
Parent Infant Interaction Observation 1. Was positive mother/infant interaction observed?
Yes
No
N/A
2. Does mother look and smile at infant frequently?
Yes
No
N/A
3. Does mother have positive observations about baby?
Yes
No
N/A
4. Does mother touch, massage or gently rub baby?
Yes
No
N/A
****If needed, please make referral****
Depression 1. Depression screening PHQ-2 completed?
Yes
No
2. Did the client respond “yes” to at least one question on PHQ-2?
Yes
No
Yes
No
If yes, complete PHQ-9 3. PHQ-9 completed? If yes, score: ****If depression present, please make referral*
Declined to state Declined to state
Risk Categories 1. Did client discuss or have any of the following? 2.
Homelessness
Domestic Violence
Depression (>10 PHQ9)
Mental Illness
Substance Abuse
Infant in NICU
Hospitalization Beyond 48-72 Hours
Child Abuse
Medical Infant
Medical Mother
Infant Delay
None
Other: ______________
DCFS Case
Extreme Financial Hardship
(shelter, motel, care, in temporary living)
Specify:
Specify:
Trauma/History of
Teen
Pre-literacy Activities 1. Is family engaging in pre-literacy activities?
Yes
No
2. New Parent Kit provided?
Yes
No
End Time: ____:_____
Rev. 8/1/12
N/A
Declined to State
Total length of visit: ________ minutes
Maternal and Child Health Access
Parent Coach:
Welcome Baby
Postpartum: Call at 2 months Date:
Start time:
Client ID #:
Supervisor:
Visit Information Attempted visit #1:
Attempted visit #2:
Attempted visit #3:
Changes in address or phone #: Mom/Client name:
Health Care and Public Benefits 1. Do you still have health insurance?
Yes
No
If yes, check all that apply Medi-Cal Presumptive Eligibility
Restricted Medi-Cal
Medi-Cal Managed Care
Full-Scope Medi-Cal
Healthy Families
Healthy Kids
AIM
No health insurance
Private health insurance: ______________
Other:
2. Have you changed providers?
Yes
No
Yes
No
Yes
No
5. Has the baby received his/her health insurance card?
Yes
No
6. Have you attended the first well baby checkup?
Yes
No
7. Have you scheduled an appointment for the 2
Yes
No
If yes, new provider: 3. Has the newborn changed providers? If yes, new provider: 4. Have you attended your appointment for your postpartum check-up? If yes, date:
______________
month well-baby checkup? 8. Have you attended the 2 month well-baby checkup?
Yes
No
9. Is the newborn receiving any public benefits?
Yes
No
If yes, which? (check all that apply) CalWORKs
Food Stamps
Homeless Assistance
WIC
General Relief
SSI/SSD
CCS
None
Declined to respond
Other:
10. Is the newborn eligible, but not receiving any of the above?
Yes
No
If yes, which? ****If needed, please make referral****
Breastfeeding 1. How are you feeding your baby? Breast only
Mostly breast, with some formula
Mostly formula, with some breast
2. Breastfeeding education or support provided?
Yes
Formula
Other:
No
3. If client stopped breastfeeding, please check the reasons for this: (check all that apply) Not enough milk
Sore or cracked nipples
Pain
Latch-on difficulties
Medical reason
Return to work
Medication
Lack of support from partner
Lack of support from family
Other:
4. How long did you breastfeed?
days
weeks
months
****If needed, please make referral****
Social Support and Involvement of Father/Secondary Caregiver 1. Do you have someone to help you with the baby?
Yes
No
N/A
Declined to state
2. Do you have someone to help you with daily chores?
Yes
No
N/A
Declined to state
3. Do you have someone to help you with other children?
Yes
No
N/A
Declined to state
4. Do you have someone to talk to you when you have questions, challenges or worries?
Yes
No
N/A
Declined to state
****If needed, please make referral****
Depression 1. Depression screening PHQ-2 completed?
Yes
No
2. Did the client respond “yes” to at least one question on PHQ-2?
Yes
No
Yes
No
If yes, complete PHQ-9 3. PHQ-9 completed? If yes, score: ****If depression present, please make referral**** End Time: ____:_____
Rev. 10/26/11
Total length of visit: ________ minutes
Maternal and Child Health Access
Parent Coach:
Welcome Baby
Postpartum: 3-4 Month Visit Date:
Start time:
Client ID #:
Supervisor:
Visit Information Attempted visit #1:
Attempted visit #2:
Attempted visit #3:
Changes in address or phone #: Mom/Client name: 1. Location of Visit: Participant’s home
Medical provider office
WIC office
Home visiting office
Other: ______________
Grandparent
Siblings
Supervisor (observation)
2. Who participated in this home visit? Mother/Client
Secondary caregiver/Father
Other: ______________ 3. Was infant present?
Yes
No
If no, why?
Health Care and Public Benefits 1. Do you still have health insurance?
Yes
No
If yes, check all that apply Medi-Cal Presumptive Eligibility
Restricted Medi-Cal
Medi-Cal Managed Care
Full-Scope Medi-Cal
Healthy Families
Healthy Kids
AIM
No health insurance
Private health insurance: ______________
Other: ______________
2. Have you changed providers?
Yes
No
Yes
No
If yes, new provider: 3. Have you attended your postpartum check-up? If yes, date: (If the client did not receive it by the 1-2 month visit, ask the following question) 4. Has the baby received his/her health insurance card?
Yes
No
5. Have you changed the infant's medical provider?
Yes
No
6. Have you attended the 2 month well-baby check up?
Yes
No
7. Have you scheduled the 4 month well-baby check up?
Yes
No
8. Have you attended the 4 month well-baby check up?
Yes
No
9. Do you have your infant's immunization record?
Yes
No
10. Has your infant received the recommended immunizations for their age?
Yes
No
11. Have there been any changes in need for public benefits?
Yes
No
If yes, new provider:
****If needed, please make referral****
Employment 1. Are you currently employed?
Yes
No
2. If no, are you looking for work?
Yes
No
Yes
No
3. If yes, how many hours/week? _________ 4. If yes, are you on maternity leave?
Breastfeeding 1. How are you feeding your baby? Breast only
Mostly breast, with some formula
Mostly formula, with some breast
Formula
Solids and/or baby cereal/ baby foods
Other: 2. Breastfeeding education or support provided?
Yes
No
3. Breastfeeding assistance provided?
Yes
No
If yes, what type: (check all that apply) Latch-on & positioning
Pumping
Engorgement
Sore nipples
Milk supply
4. If client stopped breastfeeding, please check the reasons for this: (check all that apply) Not enough milk
Sore or cracked nipples
Pain
Latch-on difficulties
Medical reason
Return to work
Medication
Lack of support from partner
Lack of support from family
Other:
5. How long did you breastfeed?
days
weeks
months
****If needed, please make referral****
Home Safety Assessment 1. Since your baby was born, has he/she been injured seriously enough that it required an emergency room or urgent care visit?
Yes
No
2. What was the cause of injury? Motor vehicle injury
Accidental fall
Declined to state
Other: ______________
Hit or cut by an object
If other, please specify: 3. Was a home safety item given? 4. Has the family made a home safety improvement and/or childproofed the home? If yes, please specify: ****If needed, please make referral****
Fire/Burns/Scald
Yes
No
N/A
Yes
No
N/A
Accidental poisoning
Social Support and Involvement of Father/Secondary Caregiver 1. Do you have someone you can count on to listen when you need to talk?
Yes
No
N/A
Declined to state
2. Do you have someone who helps you when times are stressful?
Yes
No
N/A
Declined to state
3. Do you have help with caring for the baby from the father/secondary caregiver?
Yes
No
N/A
Declined to state
4. Do you have someone to help you with daily chores?
Yes
No
N/A
Declined to state
No
N/A
****If needed, please make referral****
Pre-literacy Activities 1. Is family engaging in pre-literacy activities?
Yes
****If needed, please make referral****
Child Development 1. Was ASQ completed? ASQ
Yes Score
No
Under Cutoff
2. Communication
Yes
No
3. Gross motor
Yes
No
4. Fine motor
Yes
No
5. Problem solving
Yes
No
6. Personal/Social
Yes
No
7. Was developmental issue identified?
Yes
No
8. Was this ASQ reviewed by child developmental specialists?
Yes
No
9. Was the infant referred to regional center or other community-based organization for followup?
Yes
No
10. Has the infant started receiving developmental services?
Yes
No
****If needed, please make referral****
Parent Infant Interaction Observation 1. Was positive mother/infant interaction observed?
Yes
No
N/A
2. Does mother look and smile at infant frequently?
Yes
No
N/A
3. Does mother have positive observations about baby?
Yes
No
N/A
4. Does mother touch, massage or gently rub baby?
Yes
No
N/A
****If needed, please make referral****
Depression 1. Depression screening PHQ-2 completed?
Yes
No
2. Did the client respond “yes” to at least one question on PHQ-2?
Yes
No
Yes
No
If yes, complete PHQ-9 3. PHQ-9 completed? If yes, score: ****If depression present, please make referral****
Risk Categories 1. Did client discuss or have any of the following? 2.
Homelessness
Domestic Violence
Depression (>10 PHQ9)
Mental Illness
Substance Abuse
Infant in NICU
Hospitalization Beyond 48-72 Hours
Child Abuse
Medical Infant
Medical Mother
Infant Delay
None
Other: ______________
DCFS Case
Extreme Financial Hardship
(shelter, motel, care, in temporary living)
End Time: ____:_____
Rev. 8/1/2012
Specify:
Trauma/History of
Specify:
Teen
Total length of visit: ________ minutes
Maternal and Child Health Access
Parent Coach:
Welcome Baby
Postpartum: 9 Month Visit Date:
Start time:
Client ID #:
Supervisor:
Visit Information Attempted visit #1:
Attempted visit #2:
Attempted visit #3:
Changes in address or phone #: Mom/Client name: 1. Location of Visit: Participant’s home
Medical provider office
WIC office
Home visiting office
Other: ______________
Grandparent
Siblings
Supervisor (observation)
2. Who participated in this home visit? Mother/Client
Secondary caregiver/Father
Other: ______________ 3. Was infant present?
Yes
No
If no, why?
Health Care and Public Benefits 1. Do you still have health insurance?
Yes
No
If yes, check all that apply Medi-Cal Presumptive Eligibility
Restricted Medi-Cal
Medi-Cal Managed Care
Full-Scope Medi-Cal
Healthy Families
Healthy Kids
AIM
No health insurance
Private health insurance: ______________
Other: ______________
2. Have you changed providers?
Yes
No
3. Has the baby received his/her health insurance card?
Yes
No
4. Have you changed the infant's medical provider?
Yes
No
5. Have you attended the 4 month well-baby check up?
Yes
No
6. Have you attended the 6 month well-baby check up?
Yes
No
7. Have you scheduled the 9 month well-baby check up?
Yes
No
8. Have you attended the 9 month well-baby check up?
Yes
No
9. Do you have your infant's immunization record?
Yes
No
10. Has your infant received the recommended immunizations for their age?
Yes
No
11. Have there been any changes in need for public benefits?
Yes
No
If yes, new provider:
If yes, new provider:
****If needed, please make referral****
Breastfeeding 1. How are you feeding your baby? (check all that apply) Breast only
Mostly breast, with some formula
Mostly formula, with some breast
Formula
Solids and/or baby cereal/ baby foods
Other: 2. Breastfeeding education or support provided?
Yes
No
3. Breastfeeding assistance provided?
Yes
No
If yes, what type: (check all that apply) Latch-on & positioning
Pumping
Engorgement
Sore nipples
Milk supply
4. If client stopped breastfeeding, please check the reasons for this: (check all that apply) Not enough milk
Sore or cracked nipples
Pain
Latch-on difficulties
Medical reason
Return to work
Medication
Lack of support from partner
Lack of support from family
Other:
5. How long did you breastfeed?
days
weeks
months
****If needed, please make referral****
Home Safety Assessment 1. Since your baby was born, has he/she been injured seriously enough that it required an emergency room or urgent care visit?
Yes
No
2. What was the cause of injury? Motor vehicle injury
Accidental fall
Hit or cut by an object
Declined to state
Other: ______________
Fire/Burns/Scald
Accidental poisoning
If other, please specify: 3. Was a home safety item given?
Yes
No
N/A
4. Has the family made a home safety improvement and/or childproofed the home?
Yes
No
N/A
If yes, please specify: ****If needed, please make referral****
Social Support and Involvement of Father/Secondary Caregiver 1. Do you have someone to do something enjoyable with?
Yes
No
N/A
Declined to state
2. Do you have time for yourself?
Yes
No
N/A
Declined to state
No
N/A
Declined to state
****If needed, please make referral****
Pre-literacy Activities 1. Is family engaging in pre-literacy activities? ****If needed, please make referral****
Yes
Child Development 1. Was ASQ completed? ASQ
Yes Score
No
Under Cutoff
2. Communication
Yes
No
3. Gross motor
Yes
No
4. Fine motor
Yes
No
5. Problem solving
Yes
No
6. Personal/social
Yes
No
7. Was developmental issue identified?
Yes
No
8. Was this ASQ reviewed by child developmental specialists?
Yes
No
9. Was the infant referred to regional center or other community-based organization for followup
Yes
No
10. Has the infant started receiving developmental services?
Yes
No
****If needed, please make referral****
Parent Infant Interaction Observation 1. Was positive mother/infant interaction observed?
Yes
No
N/A
2. Does mother look and smile at infant frequently?
Yes
No
N/A
3. Does mother have positive observations about baby?
Yes
No
N/A
4. Does mother touch, massage or gently rub baby?
Yes
No
N/A
****If needed, please make referral****
Depression 1. Depression screening PHQ-2 completed?
Yes
No
2. Did the client respond “yes” to at least one question on PHQ-2?
Yes
No
Yes
No
If yes, complete PHQ-9 3. PHQ-9 completed? If yes, score: ****If depression present, please make referral****
Risk Categories 1. Did client discuss or have any of the following? 2.
Homelessness
Domestic Violence
Depression (>10 PHQ9)
Mental Illness
Substance Abuse
Infant in NICU
Hospitalization Beyond 48-72 Hours
Child Abuse
Medical Infant
Medical Mother
Infant Delay
None
Other: ______________
DCFS Case
Extreme Financial Hardship
(shelter, motel, care, in temporary living)
Specify:
Specify:
Trauma/History of
Teen
F5LA New Parent Kit 1. Did the New Parent Kit increase your parenting knowledge?
Yes
No
2. Did the New Parent Kit increase your parenting skills?
Yes
No
3. Was the New Parent Kit worthwhile?
Yes
No
Best Start LA Community Utilization Data 1. How long have you lived in the neighborhood?
<1 year Yes
1-3 years No
3. In the last 6 months, have you ever visited a local library?
Yes
No
4. In the last 6 months, have you ever participated in an event that provided parenting education and/or support?
Yes
No
5. Does your family feel close to other families in the neighborhood?
Yes
No
6. Do your family members support each other when things are stressful?
Yes
No
2. In the last 6 months, have you ever visited a local park?
3 years +
****If needed, please make referral**** End Time: ____:_____ Rev. 8/1/12
Total length of visit: ________ minutes
Maternal and Child Health Access
Parent Coach:
Welcome Baby Discharge
Date Closed:
Client ID #:
DOB:
Supervisor:
Visit Information Mom/Client name: Last engagement point completed: 1. Reason for closing case: Completed program, infant is 9+ months Participant is unavailable due to school/employment Safety issue for staff Family or partner objects to program Declined further participation Out of geographical target area Lost to follow-up/unable to locate or contact Primary caregiver no longer has custody Miscarriage/pregnancy terminated Transferred: Other: Mother deceased, date: Infant deceased, date: Closure Summary: ______________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Rev. 9/14/10
Maternal and Child Health Access
Parent Coach:
Welcome Baby
Referral Tracking Form Client's name:
Client ID #:
DOB:
Child's name: Date
Type of Referral
Family Member Referred
Crisis or Routine
Name of Organization
Staff/Client Arrangement
Crisis Routine Crisis Routine Crisis Routine Crisis Routine Crisis Routine Crisis Routine Crisis Routine Crisis Routine Crisis Routine Crisis Routine Basic needs • • • • • • •
Food Housing Clothing Transportation Financial Utilities Appliances/ Furniture • Baby Items • Other
Health/ Medical • Health insurance • Dental insurance • Health/ medical care • Dental • Lactation services • Environmental home assessment • Prenatal Care • Family Planning • Well Child Care • Adult disability-Medical • Adult disability-Mental • Translation Services • Recreation • Other
• • • • • • • • • • • • • • • •
Health Education
Perinatal mood disorder Family/couples issue Mental illness (chronic) Domestic Violence Child Abuse/Neglect Maternal depression Domestic violence Child abuse/neglect Social support Male involvement Substance abuse Infant mental health Trauma Bereavement Gang Intervention Other
• Prenatal education • Childbirth education • Infant/childcare education • Breastfeeding education/ support group • Smoking cessation • Nutrition Education • Doula • Other
1. Agency is not accepting new clients 2. Location too far 3. Agency does not accept Medi-Cal 4. Agency does not accept insurance 5. Client does not have funds 6. Client did not make the appointment 7. Client lost to f/u 8. Family placed on waiting list
Rev. 6/26/12
Staff Client Staff Client Staff Client Staff Client Staff Client Staff Client Staff Client Staff Client Staff Client Staff Client
Psychosocial
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Career and Education • Adult • • • • • •
education Job training Career development/e mployment ESL Adult Literacy Financial Literacy Other
9. Family did not qualify 10. Family declined services 11. Services not offered 12. Other 13. Appointment scheduled for a future date 14. Client unsatisfied with agency 15. Agency has not followed up 16. Client began receiving services elsewhere
If no (see codes below)
Services Received?
Child Development • Childcare • Early • • • • •
intervention/ disabilities Parenting education Early literacy After school/tutoring Preschool Other
Legal/Advocacy • • • • • • • • •
Immigration Legal services Family law Health advocacy Adoption Tenant Housing Foreclosure Other Legal Services
1111 W. Sixth Street, Fourth Floor Los Angeles, CA 90017-1800 Tel 213.749.4261 Fax 213.213.1276 www.mchaccess.org To be completed by WB staff: Date:
Parent Coach(es):
# of contacts received:
Welcome Baby Satisfaction Survey Please give us your honest feedback about your experience with the Welcome Baby program. The information you share will help us improve the services and meet the needs of other moms.
Yes
Are you a first time mother?
No
Please circle the answer that most reflects how much the Welcome Baby program assisted you in the areas listed below: Not applicable Not at all Some A lot Learning how to parent my baby
0
1
2
3
Breastfeeding
0
1
2
3
Understanding my infant’s development
0
1
2
3
Increasing my confidence in parenting my child
0
1
2
3
Learning how to bond with my baby and understand his/her cues
0
1
2
3
Receiving care for my own health needs
0
1
2
3
Making sure my home is safe for my baby (childproofing, using a car seat, a safe place for my baby to sleep, keeping my baby away from cigarette smoke and chemicals, etc.)
0
1
2
3
Receiving other services (like WIC, food stamps, counseling, etc.)
0
1
2
3
Increasing my involvement in the community (going to the library, parks, classes, support groups, etc.)
0
1
2
3
Answering my questions and concerns
0
1
2
3
Providing information in a way that respected my culture and beliefs
0
1
2
3
Supporting me in my role as a mother
0
1
2
3
Overall satisfaction with the services
0
1
2
3
Please tell us how helpful the following items were for you. Please circle “0” if you did not receive that item. Not applicable
Not at all
Some
A lot
Boppy nursing pillow
0
1
2
3
New Parent Kit (the box with information and DVD)
0
1
2
3
Home safety/childproofing items
0
1
2
3
Early Moments Matter (Handbook on early attachment and DVD)
0
1
2
3
Developmental toys
0
1
2
3
Medical Kit
0
1
2
3
What was the main benefit that you received from the Welcome Baby program?
What suggestions do you have for improving the Welcome Baby program?
Please mail the survey in the stamped, self-addressed envelope that was provided to you at your earliest convenience. Thank you very much for your feedback.
1111 W. Sixth Street, Fourth Floor Los Angeles, CA 90017-1800 Tel 213.749.4261 Fax 213.213.1276 www.mchaccess.org To be completed by WB staff: Date:
Parent Coach(es):
# of contacts received:
Encuesta de Satisfacción del Programa Welcome Baby Por favor denos su opinión sobre su experiencia con el programa Welcome Baby. La información que usted provee nos ayudará a mejorar nuestros servicios y a satisfacer las necesidades de otras mamas. ¿Es usted una mamá primeriza?
Sí
No
Por favor marque la respuesta que mejor refleje cuanto le ayudo el programa Welcome Baby en las siguientes áreas: No aplica Para nada Algo Mucho Aprendí como criar a mi bebé
0
1
2
3
Amamantación
0
1
2
3
A entender el desarrollo de mi bebé
0
1
2
3
A darme más confianza en como criar a mi bebé
0
1
2
3
Aprendí como apegarme a mi bebé y entender sus señales
0
1
2
3
Recibí cuidado para mis necesidades de salud
0
1
2
3
Me ayudaron a hacer mi hogar más seguro para mi bebé (a prueba de riesgos, usando un asiento infantil de seguridad, un lugar seguro para dormir, manteniendo a mi bebé lejos del humo de cigarrillo y químicos, etc.)
0
1
2
3
Recibí otros servicios (como WIC, estampillas de comida, consejería, etc.)
0
1
2
3
Me ayudaron a involucrarme más en la comunidad (yendo a la biblioteca, parques, clases, grupos de apoyo, etc.)
0
1
2
3
Contestaron mis preguntas y me ayudaron con mis inquietudes
0
1
2
3
Me dieron información de una manera que respeto mi cultura y mis creencias
0
1
2
3
No aplica
Para nada
Algo
Mucho
Me apoyaron a desarrollarme como mamá
0
1
2
3
Satisfacción con los servicios en general
0
1
2
3
Por favor díganos cuan útiles le han sido los siguientes artículos. Por favor marque “0” si usted no recibió ese artículo. No aplicable
Para nada
Algo
Mucho
“Boppy” almohada para amamantar
0
1
2
3
Paquete de Recursos para Nuevos Padres (la caja con información y discos compactos)
0
1
2
3
Artículos para la seguridad en el hogar y a prueba de niños
0
1
2
3
Los Primeros Momentos Importan (La guía sobre el apego temprano y DVD)
0
1
2
3
Juguetes para estimular el desarrollo del bebé
0
1
2
3
Kit de salud para bebés
0
1
2
3
¿Cuál fue el beneficio más importante que usted recibió del programa Welcome Baby?
¿Cuales sugerencias tiene para mejorar el programa Welcome Baby?
Por favor envié la encuesta en el sobre con estampilla que se le fue proveído, tan pronto como se le sea posible. Muchas gracias por sus comentarios
