Mama Matters Registration Form
If you are already enrolled in Medicaid, or are age 19 and under, please complete this form to enroll in the Mama Matters program. If you do not meet these qualifications, please contact us at (970) 210-7156 to apply for the Mama Matters program.
Mother's Name (first & last)
Estimated Due Date
We would like to have contact information for you and for a support person who may be making scheduling arrangements with us after the birth of your baby.
Please include city and zip code
Support Person's Name
Support Person's Relationship to Mother
Support Person's Phone
To best serve you, please provide us with some information about your plans for this birth, and any previous birth experiences.
Care Provider's Name
Care Provider Type
Certified Nurse Midwife
St. Mary's Hospital in Grand Junction
Valley View Hospital in Glenwood Springs
Montrose Menorial Hospital in Montrose
Delta County Memorial Hospital in Delta
Moab Regional Hospital in Moab
How many times have you previously given birth?
Previous Birth Experiences
If you have previously given birth, did you reach your goals for the birth experience?
Pregnancy Complications & Medications
Are you experiencing any complications or taking any medications during this pregnancy, or did you during any previous pregnancies?
Please provide the following information to help us determine if you qualify for our sliding scale services.
Do any of the following categories apply to your current pregnancy?
Mom under 20 years old
Mom over 40 years old
Survivor of abuse or assault
Placing baby for adoption
History of serious depression or mood disorder
Special needs baby
Are you currently enrolled in Medicaid?
Are you currently enrolled in the Nurse Family Partnership?
What is your Nurse Family Partnership visiting nurse's name?
Which of our services are you applying for?
Depending on availability, we may be able to approve sliding-scale fees for one or some of the services you are seeking.
Doula Services - $45 registration fee
Placenta Encapsulation - $97.00 materials fee
Hypnobabies® Class Series - $55 materials fee
Is there any other hardship information you would like us to be aware of?
Just one more question...
How were you referred to the Mama Matters program?
Nurse Family Partnership
Your Care Provider
Grand Valley Moms for Moms
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