Follow-Up Form - First 5 Yolo

We’d Love to Hear From You!

We hope you and your baby are doing well and enjoying these special first few months together! Since it’s been about 2½–3 months since your nurse visit, we’d love to check in and see how your family is doing.

We also want to hear about your experience with your nurse visit. Your feedback helps us learn what we’re doing well and how we can continue to better support families like yours.

Toward the end of this form, you’ll be asked to complete a brief depression screening. This is a routine part of our follow-up and helps us better understand how you’re feeling. If your responses indicate that additional support may be helpful, a member of our team may reach out to check in with you. If you’d like to speak with someone sooner or have any questions, please don’t hesitate to contact us at 916-403-2905.

First Name

Last Name

Survey Date:

Your date of birth:

Your baby’s date of birth:

How have you been feeding your baby for the past week?

Did the Welcome Baby visit change how confident you felt in breastfeeding your baby?

How are you feeling about your baby’s growth and development?

Growth and development comments:

Have you used any of these programs?

WIC

Help Me Grow

Home Visiting

Growing Together Program

Yolo Crisis Nursery

Empower Yolo

YCCA

RISE

Are you currently enrolled in a home visiting program?

Other home visiting program – please list

Have you faced any of the following barriers to accessing healthcare or community resources? Please select all that apply.

Transportation

Childcare

Cost

Discrimination / fear

Language/Literacy

Time (inconvenient/long/work conflicts)

Other

None

Please write other barriers to healthcare/resources:

Are you currently working, attending school, or planning to start work or school?

Do you need any of the following resources?

Have you utilized the Emergency Department (ER) or Urgent Care for yourself since your baby was born?

Did you complete a postpartum visit within 21 days of giving birth?

Postpartum visit 1 date (approximate is okay):

Did you complete a postpartum visit within 22–84 days of giving birth?

Postpartum visit 2 date (approximate is okay):

Have you utilized the Emergency Department (ER) or Urgent Care for your baby since your baby was born?

Did your baby attend a well-baby visit with their primary care provider or pediatrician when they were 1 to 5 days old?

Did your baby attend a well-baby visit with their primary care provider or pediatrician when they were 2 weeks to 1 month old?

Did your baby attend a well-baby visit with their primary care provider or pediatrician when they were 1 month to 2 months old?

Instructions: Over the last 2 weeks, how often have you been bothered by any of the following?

Feeling down, depressed, or hopeless?

Little interest/pleasure doing things?

Nervous, anxious, or on edge?

Not able to stop or control worrying?

Would you recommend Welcome Baby to a friend?

While in Welcome Baby, did you feel heard, understood, and respected?

Do you have any other comments?

September 16, 2022

First 5 Yolo Launches Grants for Childcare Providers

First 5 Yolo is excited to announce funding opportunities available through the Childcare Recovery Package,[...]

March 30, 2022

First 5 Yolo Launches Welcome Baby

Welcome Baby expands First 5 Yolo's navigation and home visiting initiative (R2R) and reaches Medi-Cal[...]

January 7, 2021

The COVID-19 Vaccine

For Expecting and New Parents: What You Need to Know about the COVID-19 Vaccine[...]

January 7, 2021

Routine Vaccinations

For Expecting and New Parents: What You Need To Know about Routine Vaccinations[...]

See All Posts