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Apply For Care

The Care For Women program is available to women who find themselves feeling alone in their transition to motherhood. This may be for many reasons such as not having a supportive partner, family available, having moved to a new region and many others.

We are accepting applications for pregnant mothers in need of assistance in Abbotsford, Mission, Langley and Chilliwack, BC.

You will be connected with a mentor before your due date who will support you up to approximately 4 weeks postpartum. *Information collected below is designed to receive funding to carry on the program and support as many women as we can accommodate at this time.

Applicants must be still be pregnant at the time of application

*IF YOU ARE RECEIVING AN ERROR MESSAGE WHEN TRYING TO SUBMIT THE APPLICATION, PLEASE EMAIL US AT HELLO@CAREFORWOMEN.CA AND WE WILL SEND YOU THE APPLICATION FORM DIRECTLY.

Who is applying? *

If you are applying on behalf of someone else, please include your full name, email address and phone number so we are able to connect with you: *

Name *

LAST NAME, First Name

Date Of Application *

Birth Date *

Age *

Email *

Phone Number *

Is it okay to phone/text/email you if we need to? *

To be eligible for care we will need to contact you

Are you Immigrant to Canada *

Do you identify as Indigenous? *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Occupation *

Primary language spoken? *

Are you able to understand and communicate in English? *

Do you drive? *

What is your household income? *

Please choose one of the above options

Please check all that apply: *

I am a single parent family
I was directly referred by a medical professional
I am experiencing homelessness or am in transitional housing
I am 19 years or younger
I am a mother who is fleeing domestic violence
I am recovering from substance misuse
I struggle with mental health (e.g. anxiety, OCD, depression, history of postpartum anxiety or depression)
None of the above applies to me

What is your current living arrangement? *

How many weeks pregnant are you? *

Due Date or C- Section Date *

How many other children do you have in your household? *

Do you have any medical conditions? *

Are you on any medication? *

Have you completed high school? *

Does anyone smoke in your house? *

We ask this question for allergy reasons when matching mentors and mothers.

Do you have any pets? *

Please describe.

What is your relationship status? *

Partner's name or emergency contact

First and last name. If you do not have a partner please indicate N/A

Your partner's occupation

How old is your partner?

Your partner's or emergency contact's phone number *

How would you describe the relationship with your partner? *

Great/Supportive
Could be better
Complicated
Off and on
Not supportive of this pregnancy
Does not know about this pregnancy

Please check all that apply

How can your mentor best support during the postpartum period? *

What are your current concerns and why would our program be helpful? *

How can we best support you when you and your newborn come home? *

Who is supporting you when you come home? *

Are they taking dedicated time off to support you? *

If yes, for how long will they be supporting you?

How did you hear about our services? *

Are you comfortable with your mentor visiting you at the hospital after baby arrives? *

How will you let your mentor know once baby has arrived? (e.g. text, call from midwife, etc.) *

I will text
I will phone
My mentor can expect a phone call from a prearranged person
My mentor can expect a text from a prearranged person

Check all that apply

Are you a surrogate? *

Do you have transportation to your doctor/midwife appointments? *

How are you planning to get to the hospital for your delivery? *

Would you like to receive meals? *

Do you have any dietary restrictions? If yes, please list what they are: *

Would you like to receive a professional cleaning service?: *

If yes, are you comfortable with a cleaner coming when you are home alone? : *

What other postpartum stressors/needs do you have that we have not asked you about on this application? *

Is there anything in particular you'd like us to know or information you'd like to share?

By applying for care I understand that the heart of this program is to meet in person in my home to help me emotionally and physically for 4 weeks postpartum. *

I understand that the mentor who I am matched with has arranged her schedule to accommodate my needs and I understand that if I do not respond to my mentor within 4 attempts of my mentor reaching out, my file will be closed. *

*By applying you are agreeing to receive Care For Women newsletters

For additional inquiries about care, please contact our Program Coordinator at 778-808-2752