Midwifery Prenatal Group Care Application

Please select your estimated due date month (we recommend taking this session in your final 2 months of pregnancy):

First Name Same as your Government Identification *

Last Name Same as your Government Identification *

Email *

Name of Spouse or Emergency Contact *

By checking this box, you are giving permission for the Breastfeeding Buddies Program to receive this form via email and use your email address to communicate with you. While all precautions are taken to ensure security and privacy, email can be vulnerable to misuse. Please do not include any confidential health information on the form.

Phone Number *

Postal Code *

Please select the township/city where you live: CambridgeKitchenerWaterlooNorth Dumfries (e.g., Ayr, Roseville)Wellesley (e.g., Linwood, St. Clements, Wellesley)Wilmot (e.g., Baden, New Dundee, New Hamburg)Woolwich (e.g., Breslau, Conestogo, Elmira, St. Jacobs)

How did you hear about Community Healthcaring KW Perinatal Group Midwifery Care Please check all that apply.
Family/FriendRegion of Waterloo Public Health (Website, Nurse, Program)MidwifeDoctor/Nurse PractitionerObstetricianOntario EarlyOn CenterWaterloo Region Health Network (Grand River Hospital)Cambridge Memorial HospitalCommunity Healthcaring KWBreastfeeding Buddies WebsiteBreastfeeding Buddies Prenatal PathwaySocial Media (Facebook, Instagram, Twitter)Print Media (Poster, Pamphlet, Postcard)Other

Please note: Space in the Community Healthcaring KW Perinatal Group Midwifery Care program is reserved for expectant parents who do not have OHIP or private insurance. This application does not indicate acceptance into care. Acceptance into care will be at the discretion of Community Health Caring KW and our Midwife.

Who will be your support person during pregnancy and while giving birth?
PartnerChildRelativeFriendOther

Are you currently in your:
First TrimesterSecond TrimesterThird TrimesterI am not currently Pregnant

What is your estimated due date?

When was your last menstrual cycle?

Which healthcare provider have you seen most often during your pregnancy? Please check all that apply.
Emergency Room DoctorUrgent Care DoctorWalk In Clinic DoctorNurse PractitionerObstetricianMidwifeI have not seen a healthcare provider

We would like to know who we are reaching at the workshops. Please check all that apply to you.
I am living on a limited income (e.g. I have had to visit a food bank, I sometimes don't have money for rent)I am living in unstable housing (e.g. I am on a waiting list for housing, I have stayed at a shelter)I am new to Canada (I have lived in Canada less than ten years)I don't have many social supports (e.g. Family, friends, neighbours, community groups)None of the above

Is English your second language?
YesNo

The language I speak most often at home is:

What is your gender?
FemaleMaleTransgenderTwo-spiritIntersexDo not knowAnother (please specify)

Which of the following best describes your racial or ethnic group?
First Nations/Indigenous (e.g., Inuit, Métis)Asian – East (e.g., Chinese, Japanese, Korean)Asian – South (e.g., Indian, Pakistani, Sri Lankan)Asian – South East (e.g., Malaysian, Filipino, Vietnamese)Black – African (e.g., Ghanaian, Kenyan, Somalian)Black – Caribbean (e.g., Barbadian, Jamaican)Black – North American (e.g., Canadian, American)Indian – Caribbean (e.g., Guyanese with origins in India)Latin American (e.g., Argentinean, Chilean, Salvadorian)Middle Eastern (e.g., Egyptian, Iranian, Lebanese)White European (e.g., English, Italian, German, Portuguese)White North American (e.g., Canadian, American)Mixed heritage (e.g., Black-African and White-North American)Do not knowAnother, please specify

What is your age?

What is your highest level of school completed?
Grade 8High SchoolCollegeUniversityTrade School

Do you currently smoke?
YesNo

Is this your first pregnancy?
YesNo

Do you plan to breastfeed?
YesNoUnsure

Please indicate your level of confidence with the following:
How confident are you in your knowledge of parenting/health resources in Waterloo Region?
Very ConfidentConfidentA Little ConfidentNot Confident

How confident are you in your ability to navigate the health care system?
Very ConfidentConfidentA Little ConfidentNot Confident

How confident are you in your ability to prevent/solve parenting issues?
Very ConfidentConfidentA Little ConfidentNot Confident

Please indicate your level of comfort with the following:
How comfortable are/would you be breastfeeding your baby?
Very ConfidentConfidentA Little ConfidentNot Confident

How comfortable are/would you be asking for help with breastfeeding?
Very ConfidentConfidentA Little ConfidentNot Confident

Do you currently know where to go for breastfeeding support and resources in the community?
YesNoUnsure

If you require immediate assistance or have concerns about your baby's health, please contact your health care provider. This service is not intended to replace emergency medical care or crisis support.

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