Program Interest Form

If you are interested in more information or scheduling a visit, please complete the Family Connects Interest Form:

Information collected on this form, including personal information, will be used to help inform our team on how best to serve you and your family and for statistical data purposes. Personal data is subject to our Privacy Policy.

Parent's First Name

Parent's Last Name

Parent's Phone Number

County of Residence

Parent's Email Address

Infant Details

Infant First Name

Infant Last Name

Infant's Date of Birth

Name of Hospital/Birth Location

TOTAL number of children/dependents (include infant listed above, other children, and adult dependents)

Please use this section of the form to record information about each of your children/dependents. Enter details below about a child/dependent and, if needed, use the "Add another response" link in the lower right part of this page to add information about another child/dependent. Repeat as needed.

HOUSEHOLD MEMBER INFORMATION

Child/Dependent's First Name

Child/Dependent's Last Name

Date of Birth

What happens during a home visit?

FOR BABY

Baby weight check
Safe sleep information
Infant feeding and fussiness
Help with bathing, diapering, and swaddling

FOR BIRTHING PARENT

Health check for the birthing parent
Breastfeeding support
Family planning advice
Postpartum depression screening

FOR FAMILY

Schedule doctor’s appointments
Understanding childcare options
Early literacy information
Community resources and connections

Newborn Parent Resources

Hear how this program supports local families.

This work is funded in part by the Elizabeth A. Hudspeth Endowment Fund of the Cumberland Community Foundation and the North Carolina Partnership for Children. The program is a collaboration between the Partnership for Children of Cumberland County, the Hoke County Partnership for Children and Families, the Robeson County Partnership for Children, Family Connects International, Cape Fear Valley Health, and our nursing partner, Carolina Collaborative Community Care (4C).