For My Baby & Me Feedback Form

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We would love to know your thoughts on the For My Baby & Me (FMBAM) program. Please complete this form and leave your comments with us. Responses may be used for research and publication purposes.

[Responses are confidential and will not be linked to you or your medical records.]

Your feedback will help us to improve services for pregnant persons in our community.

First and Last Initial: *

What is your experience with the program? *

I currently am or was in the program myself

I know or knew someone who was in the program

I am a partner or supporter of the program

I have heard or seen the program, but have not engaged

Other:

Required

What are your comments about the program? *

How did you hear about the program? *

FMBAM Website or Internet

Social Media

Newsletter / Newspaper

Outdoor Advertisement

Radio

Family or Friend

Medical or Treatment Facility / Professional

Other:

Required

If we have served your needs through this program, please rate your overall experience.

Unpleasant

Exceptional

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