First Call Network Intake Form First Call Network Intake Form About YouName(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 No Have you (or your spouse/significant other) received a diagnosis of Down syndrome through a CVS or amniocentesis?(Required) Yes No 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 InformationPlease share the following information to help us make the most meaningful connection with a Parent Mentor:Residing City Primary Language English Spanish 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 InformationThis 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) Email Text Phone call Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code ConsentI 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:
