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Home Visiting San Bernardino County Interest Form
Are you currently pregnant? Are you caring for a baby under 3 months old and living in San Bernardino County? Are you interested in having a Family Support Specialist visit your home to support you and your family? Please fill out our interest form below. A CCRC representative will contact you with more information. If you have any questions about this form, please contact us at hvinfo@ccrcca.org.¿Está embarazada actualmente? ¿Está cuidando a un bebé menor de 3 meses y vive en el condado de San Bernardino? ¿Está interesado en que un Especialista en Apoyo Familiar visite su hogar para apoyarlo a usted y a su familia? Por favor, rellene nuestro formulario de interés a continuación. Un representante de CCRC se pondrá en contacto con usted para brindarle más información. Si tiene alguna pregunta sobre este formulario, contáctenos en hvinfo@ccrcca.org.
Today's Date
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Month
-
Day
Year
Date
Parent Date of Birth
*
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Month
-
Day
Year
Date
Parent Name
*
First Name
Last Name
Are you or your partner expecting/pregnant?
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Yes
No
Expectant Due Date
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Month
-
Day
Year
Date
If not pregnant, have you given birth, or in care of a child under 3 months?
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Yes
No
Other
Child's Full Name
First Name
Last Name
Child's Date of Birth
*
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Month
-
Day
Year
Date
Did you have a single birth or multiples?
*
Single/One baby
Multiples/Twins or more
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Preferred Method of contact (please check all that apply)
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Phone Call
Email
Text
Best time to Contact
*
Morning (8a-12pm)
Afternoon (12pm-3pm)
Evening (3pm-5pm)
Preferred Language Spoken at Home
*
Race/Ethnicity
*
Please Select
Hispanic
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Other
Declined to self-identify
Circumstances for Requesting Support - Please check one or more reasons listed below:
*
Low Income/Eligible to receive CalFresh, Medi-Cal, or CalWORK (Cash Aid)
Unstable Housing
Substance Use (current or history)
Less than HS Education or GED
Mental Health Condition/Diagnosis
Intimate Partner Violence/Domestic Violence (current or history)
Involvement with CPS
Other
How did you hear about us?
*
Please Select
CCRC Website
Word of Mouth/Friend
Reffered by another agency/organization
Other
Is there anything else we should know or would be helpful to be aware of?
Submit
Should be Empty: