Expectant Parent Intake Form

* = required

About You

First Name*

Last Name*

Mailing Address*

Street Address City State / Province / Region ZIP / Postal Code

Email Address*

Phone Number*

I am:

an expectant parent
the spouse or significant other of an expectant parent
the referral source for an expectant parent

Name of Referral Source

About Your Pregnancy

Have you (or your spouse/significant other) received prenatal screening test results (involving bloodwork and ultrasound) that indicate a higher chance that your baby has Down syndrome?*

Yes
No

Have you (or your spouse/significant other) received a diagnosis of Down syndrome through a CVS or amniocentesis?*

Yes
No

What is the due date?*

Year of birth of expectant mom

Optional Additional Information

Please share the following information to help us make the most meaningful connection when possible:

Ethnicity of parent(s):

Primary language of parent(s):

We may be able to connect you with a bilingual First Call parent.

Any health/medical information about mom or baby that may be helpful for us in offering the most meaningful support and resources?

Any information about your background or family structure (including ages of any other children) that may be helpful for us in offering the most meaningful support and resources?

We are here for you!

We offer a connection to a Prenatal First Call parent mentor, the parent of a younger child with Down syndrome who also learned the unexpected news of Down syndrome prenatally.

Would you like to be contacted by a Prenatal First Call parent mentor?*

yes
no, but please send me helpful information and resources

Would you prefer to be contacted initially by:

email
text
WhatsApp

We also offer resources that will be helpful to you. How would you prefer to receive these resources?

mail
email

We also offer resources that will be helpful to you. How would you prefer to receive these resources?

mail
email

Any additional information that you would like to share to best help us support you and your family:

Lastly, we are curious how you heard of the MDSC Prenatal First Call Program?

online search
social media
medical provider
other

Please share the provider’s name and/or group affiliation:

If other, please share:

Consent Form

Consent*

I have reviewed the waiver and consent

Please review this waiver/consent.

EXPECTANT PARENT MUST CHECK BOX OR SIGN FORM
I understand that I will be speaking with a trained parent volunteer and that this conversation does not represent medical advice or professional counseling. The Prenatal First Call Program does not provide advice in any way. My conversation(s) with a parent volunteer will be confidential and only a brief synopsis of our call(s) will be shared with the program's Family Support Team to ensure individualized resources and supports are provided to me. My personal information will not be shared and will be kept confidential within the Prenatal First Call Program.

If you have not heard from a First Call parent in 24 hours, you may email us at firstcall@mdsc.org

Expectant Parent Intake Form