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Lactation Care Provider Directory
The purpose of this form is to support resource building and cross-sharing of information. This form is for Healthcare providers providing lactation care to NM families. For questions regarding this form please contact
lynnae@breastfeedingnm.org
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What counties do you work in?
Your answer
What city are you in?
Your answer
Do you offer telehealth visits?
Yes
No
Other
Clear selection
Where do you practice?
Private Practice
Hospital
Clinic
Home-visiting Agency
WIC
Other (Fill in) ______________________
Other:
Clear selection
Name of Company/Organization where you practice
Your answer
What clients do you serve?
Insured
Non-insured
Self-pay
Clients must be patients of the company or organization I work with
Other:
Do you accept Medicaid?
Yes
No
Clear selection
Do you offer any of the following payment arrangements? (Check all that apply)
Free (Services provided only to patients of the company or organization I work for)
Free (I volunteer my services)
Sliding Scale Fees
Payment Plans
Other:
Full Name
Your answer
Credentials
IBCLC
CLC
Peer Counselor
Other:
Email
Your answer
Phone Number
Your answer
How would you like to be contacted?
Phone
Email
Work phone
Other:
Clear selection
Website (if applicable)
Your answer
Social Media (if applicable)
Your answer
Do you offer other services besides lactation? If so, what?
Your answer
Other than English, what languages do you speak?
Your answer
Are you interested in being listed in our Resource Directory?
Yes
No
Other:
Clear selection
Any other information you would like to share?
Your answer
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This form was created inside of New Mexico Breastfeeding Task Force.
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