top of page
Home
About Us
Board of Directors
Specialty Teams
Our Services
Scholarship Recipients
Resources
Local Resources
Educational Resources
Webinars
Community Events
Connect
Shop
Contact
More
Use tab to navigate through the menu items.
Log In
RSVP Form
*
First name
*
Last name
*
Email
*
Are you currently pregnant? (If NO, end RSVP, if YES continue into next section of questions)
Phone Number
Zip Code
Preferred Method of Contact
In which WA county do you currently reside?
Which of the following best describes your race?
American Indian or Alaska Native
Asian
Black - African American (US Born)
Black - African (Sub-Saharan)
Black - Caribbean
Black - Afro-Latino
Native Hawaiian or Other Pacific Islander
White
Other
Prefer not to say
If other, please specify:
What is your sex?
If other, please specify:
Consent for Follow-up: May we contact you in 60 days to see if you were able to connect with any resources provided today?
Do you currently have any form of health insurance or health care coverage?
[If Yes] Which of the following best describes your primary health insurance coverage?
If other, please specify:
On a scale of 1–5, how confident do you currently feel navigating your maternal or child health needs?(1: Not at all confident, 5: Completely confident).
1 – Not at all confident I feel completely unsure and don’t know where to start with my maternal or child health needs.
2 – Slightly confident I have a small understanding but I often feel unsure and need a lot of help or guidance.
3 – Moderately confident I have some knowledge and can manage parts of my care but I still need support or clarification at times
4 – Very confident I feel mostly capable and informed and I can handle most of my needs with only occasional help.
5 – Completely confident I feel fully informed capable and able to manage my needs independently.
Are you currently looking for support in any of the following areas? (Check all that apply):
Pregnancy testing
Prenatal and postpartum care
OB-GYN and/or nurse midwife support
Lactation support
Doula services
Vaccinations
STI screenings
Prenatal massage
Behavioral health check-ins
WIC/Nutrition services
Other
If other, please specify:
Do you currently have a healthcare provider for your pregnancy (e.g., OB-GYN, Midwife, or Family Doctor)?
How many prenatal appointments have you attended during this pregnancy?
How did you find your current provider?
If other, please specify:
How do you usually get to your appointments?
How long does it typically take you to travel to your provider’s office?
In the last 3 months, have you missed or delayed an appointment because of any of the following? (Check all that apply):
Lack of transportation
Difficulty finding childcare for other children
Unable to take time off work
Office hours do not fit my schedule
Financial concerns/cost
On a scale of 1–5, how easy is it to schedule an appointment when you need one? (1: Difficult and discouraging, 5: Easy and convenient)
1
2
3
4
5
If you have a medical question between appointments, how do you typically reach your provider?
How long do you usually wait in the waiting room before being seen?
Do you feel your provider listens to your concerns and explains things in a way you understand?
To what extent do you feel your healthcare provider incorporates your personal preferences into your treatment or care plan?
Do you feel comfortable and safe sharing your personal health goals or fears with your current provider?
How important is it to you that your provider shares your cultural background or speaks your primary language?
Are you concerned about the cost of your prenatal care or the upcoming delivery?
Do you have any unmet needs that make it hard to focus on your health (e.g., stable housing, enough food, or safe environment)?
SUBMIT
Free Community Pop-Up Clinic
Nov 07, 2026, 11:00 AM – 4:00 PM PST
Eastside Community Center
bottom of page
