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First Call Network Intake Form

About You

Name(Required)

First Last

I am(Required)

an expectant parent

the parent of a newborn

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(Required)

MM slash DD slash YYYY

Child's Name(Required)

First Last

Child's Birth Date(Required)

MM slash DD slash YYYY

Optional Information

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

Residing City

Primary Language

English

Spanish

Other

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)

Any health/medical information about the baby and/or pregnancy that could be helpful to us when matching you with a Parent Mentor?

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

Email(Required)

Phone(Required)

Address(Required)

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

Consent

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.(Required)

I understand

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

Name

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

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.

Programs & Services

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First Call Network Intake Form