Healthy Families Rappahannock Area Questionnaire
Healthy Families is a living breathing manual that offers a nationally accredited program that provides the tools, guidance and support that families need to build a healthy, successful life. We provide free services in the localities of Caroline, Fredericksburg City, King George, Stafford, and Spotsylvania. Once a family is enrolled, a family support specialist provides regular home visits from pregnancy until child reaches the age of 3 or 4 so they can learn how to recognize and respond to their babies’ changing developmental needs, use positive discipline techniques, cope with the day-to-day stress of parenting in healthy ways, and set and achieve family goals.

The first five questions are required. To be able to submit this questionnaire, please answer the first five questions even if you are not interested in receiving services. You will not be contacted if you select "I do not wish to be contacted" below, your responses will only be used for statistical purposes. Thank you!
Email *
Mother's Name *
I have received information on Healthy Families and: *
I am completing this survey: *
Marital Status: *
I live in: *
Address
Date of Birth
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Phone Number
My preferred method to be contacted is:
Clear selection
My babies father's name is:
His date of birth is:
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My baby's name:
Please enter your baby's DOB or expected DOB
MM
/
DD
/
YYYY
My first prenatal visit was between
Clear selection
I am currently:
Clear selection
My income is sufficient to meet my needs
Clear selection
I currently receive the following assistance:
Is your family (including the father of the baby) happy and supportive of this pregnancy?
Clear selection
Right now I feel (check all that apply):
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