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Worksheet

T.R.I.B.E. Perinatal Pilot Program Application

To apply to be one of the seven pregnant people in northwest Dayton who will have the opportunity to work with a T.R.I.B.E. support team throughout pregnancy, birth, and postpartum transition, please complete and save the application below.

Ideally, these seven people would have an expected due date of no later than July, 2024.

1. ➜

Your Name

2. ➜

Expected Due Date

3. ➜

Zip Code

4. ➜

Your Birthday

5. ➜

Race

6. ➜

Gender Identification

How do you identify? (she/her, they/them, etc.)

7. ➜

Primary Language

8. ➜

Cultural Considerations

Do you have any cultural considerations regarding your pregnancy or birth journey, beliefs, or practices?

9. ➜

Relationship Status

Are you single, married, or in a committed relationship? Do you have a partner on your pregnancy journey? If so, what is their name and relationship to you?

10. ➜

Number of pregnancies

How many total pregnancies have you had including this one?

11. ➜

Number of living children

12. ➜

History of birthing trauma

Do you have any history of previous birthing trauma that you'd like to share?

13. ➜

Feeding options for baby

How do you plan to nourish your new baby?

14. ➜

Labor preferences

What kind of labor do you plan to have? (it's more than okay if you aren't sure yet)

15. ➜

Who will attend your labor?

16. ➜

Who is your OBGYN provider?

17. ➜

When is/was your first prenatal doctor's visit?

18. ➜

Physical health history

Please list and describe any existing physical health history including any diagnoses, medications, hospitalizations, and pertinent family history.

19. ➜

Mental health history

Please list and describe any existing mental health history including any diagnoses, medications, hospitalizations, and pertinent family history.

20. ➜

Who is your Primary Care Provider?

21. ➜

Substance use history

Please list and describe any substance use disorder (past or present).

22. ➜

Occupation / Daily Activities

Are you currently working, in school, a stay at home parent, or participating in any activities on a regular basis? If so, please describe to help us learn more about you and your availability.

23. ➜

Notes

Please share any other information you'd like for us to know.