CJFHC Mother-Baby Prenatal and Postpartum Personal Concierge®

Congratulations! We are here to help as you enter this exciting time!

This program will act as your Personal Concierge, guiding you through proper self-care and care for your baby once he or she arrives. We will send you up to 6 care messages per week via text message. This information does not replace your doctor's care; it is meant as an extra resource for you.

To make sure we send you information that will help you and your baby most, please complete this quick survey below to join the program.

Fields marked with an asterisk (*) are required

Are you a*

Mother
Other

You selected "other", please describe:*

First Name*

Mobile Number*

You will receive text (SMS) messages from the number 52046. Message & data rates may apply according to your carrier rate plan. There are no additional charges. You may unsubscribe at anytime by texting STOP. For assistance with the program, text HELP.

ZIP Code*

County of Residence*

Mother's Year of Birth*

Have you given birth to your child?*

Yes
No

What is your baby's date of birth?*

What is your due date?*

Have you taken drugs, smoked or consumed alcohol at any point during this pregnancy?*

Yes
No

Are you currently engaged in a substance abuse disorder treatment program?*

Yes
No

What is the name of your substance abuse disorder treatment program?*

Which of the topics below would you be interested in receiving information about?*

Practical/Social - i.e. child care, housing, insurance/financial, transportation
Physical – i.e. postpartum recovery, routine check-ups, substance abuse, post labor pain
Emotional - i.e. depression, fears, sadness, worry
Spiritual – i.e. questioning of faith, loss of purpose or meaning
Family - i.e. dealing with children/partner, family health issues

Please indicate your level of agreement or disagreement with the following statements:*

	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
I am confident of my ability to manage my everyday life
I am confident of my parenting skills
I am confident of my ability to manage substance abuse
I know the different medical treatment options for my substance abuse:
I can follow through on actions I need to do at home (i.e. housekeeping, paying bills on time, etc.):
I am the person who is responsible for managing my health.

Terms & Conditions*

I have read and accepted the Terms & Conditions for this text message program.