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First Call Network Intake Form

Name

This field is for validation purposes and should be left unchanged.

About You

Name(Required)

First Last

I am(Required)

an expectant parent

the parent of a child with Down syndrome (Age 0-5)

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?(Required)

Yes

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

Yes

Due Date or Date of Birth

MM slash DD slash YYYY

Child's Name(Required)

First Middle Last

Contact Information

This information will be kept confidential and will not be shared without your permission.

What level of support would you like?(Required)

I want to be connected with a Parent Mentor

I DO NOT want to be connected with a Parent Mentor, but please send me more information about Down syndrome and local resources

What is your preferred method of contact?(Required)

Text

Phone call

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Demographic Information

Please share the following information to help us make the most meaningful connection with a Parent Mentor:

Residing County(Required)

Child's Gender Identity

Male

Female

Other

Prefer not to answer

Child's Ethnicity

Asian or Pacific Islander

Black or African American

Hispanic or Latino

Native American or Alaskan Native

White or Caucasian

Multiracial

Other

Check all that apply.

Other (please describe)

Primary Language Spoken at Home

English

Spanish

Other

Health Insurance Type

Medicaid

Private Insurance

Uninsured

Other

Primary Caregiver's Education Level

Less than High School

High School/GED

Some College/Trade School

Associate's Degree

Bachelor's Degree

Graduate Degree

Prefer not to answer

Primary Caregiver's Employment Status

Employed Full-time

Employed Part-time

Unemployed

Student

Stay-at-Home Parent

Retired

Other

Primary Caregiver's Marital Status

Single

Married

Partnered

Divorced/Separated

Widowed

Household Income Range

Under $25,000

$25,000-$49,999

$50,000-$74,999

$75,000-$99,999

$100,000+

Prefer not to answer

Have you received a Congrats Pack or Welcome Basket?

Yes

Consent(Required)

I understand that I will be speaking with a trained Parent Mentor and that this conversation does not represent medical advice or professional counseling. DSAWM does not provide advice in any way. My conversation(s) with a Parent Mentor will be confidential and only a brief synopsis of our call(s) will be shared with DSAWM to ensure individualized resources and supports are provided to me. My personal information will not be shared and will be kept confidential within the DSAWM database.

I agree

I disagree

Kent County Residents(Required)

Kent County's Ready by Millage is providing the funding for the services you are receiving. By providing your consent, you understand the following about the First Call Call Services funded with Ready by Five Early Childhood Millage funds: DSAWM is required to collect information about you and your child. Your information will be shared with the Kent County Health Department, Kent ISD and First Steps Kent for the purposes of community reporting, program improvement and evaluation. All reports made publicly available will not name you or your child received a millage-funded service.

I agree

I disagree

N/A

Please share any additional information that may be helpful to us before connecting you with a Parent Mentor:

Address

160 68th St. SW, Ste. 110
Grand Rapids, MI 49548
Located inside the Special Olympics Michigan Unified Sports & Inclusion Center

Phone

616-956-3488

Hours

Monday – Thursday | 9:00am – 5:00pm

DSAWM is a proud member of the Global Down Syndrome Foundation, an organization dedicated to significantly improving the lives of people with Down syndrome through Research, Medical Care, Education, and Advocacy.

DSAWM is a member of Down Syndrome Affiliates in Action, an association of local, state, and regional Down syndrome organizations who share experiences, exchange program materials, and find ways to learn from each other.

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First Call Network Intake Form