HANDS Referral Submit a HANDS Referral If you or someone you know would be interested in participating in the HANDS program, please fill out the referral form below. This field is hidden when viewing the formNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.HANDS Referral FormWho are you referring?(Required)Select the best optionMyselfSomebody elseAbout YouYour Name(Required) First Last Which best describes you?(Required) I am pregnant My partner is pregnant I have a new baby (less than 90 days old) Baby's Birthdate(Required)Estimated Due Date(Required)Your Contact InformationPreferred Method of Contact(Required)Choose all that apply Phone Call Text Message Email Email Address(Required) Email Address Confirm Email Address Phone Number(Required)Best Time to Call(Required) Morning (8:00 am - 12:00 pm) Afternoon (12:00 pm - 4:00 pm) Evening (4:00 pm - 8:00 pm) Select AllMay we leave a message?(Required) Yes No If interpretation services are needed, please list primary language.OutreachThe following question helps us determine how we can best tell others about the HANDS program.How did you hear about the HANDS program?Select all that apply My doctor My child's pediatrician Daycare/School Resource Fair (or similar event) Social Media Traditional Media (newspaper, radio, billboard, etc.) Word of Mouth Other You selected "Other" - how did you hear about the HANDS program?Comments/QuestionsAbout the Parent/GuardianParent/Guardian's Contact InformationName(Required) First Last Which best describes the parent/guardian?(Required) The parent/guardian is pregnant Their partner is pregnant They have a new baby (less than 90 days old) Baby's Birthdate(Required)Estimated Due Date(Required)Preferred Method of Contact(Required)Choose all that apply Phone Call Text Message Email Email Address(Required) Email Address Confirm Email Address Phone Number(Required)Best Time to Call(Required)Select all that apply Morning (8:00 am - 12:00 pm) Afternoon (12:00 pm - 4:00 pm) Evening (4:00 pm - 8:00 pm) Unsure Select AllMay we leave a message?(Required) Yes No Unsure If interpretation services are needed, please list primary language.Your InformationWhat is your relationship to the parent/guardian? Primary Care Physician OB/GYN Baby's Pediatrician Family Member Friend Other You selected "Other" - what is your relationship to the parent/guardian?Your Name Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. First Last Comments/Questions
