First Name*

Last Initial*

Email *

By checking this box, you are giving permission for the Breastfeeding Buddies Program to receive this form via email and use your email address to communicate with you. While all precautions are taken to ensure security and privacy, email can be vulnerable to misuse. Please do not include any confidential health information on the form.

Phone Number *

What is your preferred method of contact?
---Phone Call (Landline no text)Text MessageEmail

What is your age?
15-2021-2526-3031-3536-40over 40

What are your Pronouns? check one or more options for the set of pronouns you want people to use when they refer to you
---She/HerThey/ThemZe/HirXe/XirHe/HimSomething Else

When was your baby born or what is your due date? YYYY-MM-DD format (e.g. 2018-04-08)

We would like to know how to best support families. Please check all that apply to you. This information will be kept confidential and adhere to KDCHC privacy policies.
I am living on a limited income (e.g. I have had to visit a food bank, I sometimes don't have money for rent)I am living in unstable housing (e.g. I am on the waiting list for housing, I have stayed at a shelter)I am new to Canada (I have lived in Canada less than five years)I don't have many social supports (e.g. Family, friends, neighbours, community groups)Prefer not to answerNone of the above

We want to know how far our reach goes! Please select the region where you live:
Waterloo RegionGuelph-WellingtonLambtonGTAHamilton/NiagaraOttawa/Northern OntarioOther

Is English your second language?
---YesNo

What is your highest level of school completed?
---Grade 8High SchoolCollegeUniversityTrade School

What is your postal code?

How did you hear about the Breastfeeding Buddies peer support Buddy Match Program? Please check all that apply
Family/FriendRegion of Waterloo Public Health (Website, nurse, program)MidwifeObstetricianDoctor/Nurse PractitionerOntario EarlyOn Center/EarlyOn StaffGrand River HospitalCambridge Memorial HospitalBreastfeeding Buddies WebsiteNorth/West Lambton CHCGuelph CHCMe Breastfeed WorkshopSocial Media (Facebook, Instagram, Twitter)Print Media (Poster, pamphlet, postcard)Other/Not Sure

Have you breastfed, chestfed, or pumped for a child before?
YesNo

For how long did you breastfeed, chestfeed, or pump?
Birth to 3 Months3 to 6 Months6 to 12 MonthsOver 12 MonthsI have never breastfed a child

What health care provider did you see most often during your pregnancy? Please check all that apply.
DoctorNurse PractitionerObstetricianMidwife

Are you requesting to be matched with a specific Buddy?
YesNo

If Yes, what is the buddy's name?

Please include any information that may help match you with a buddy with similar lived experience (for example twins/multiples, health condition, mental health, addiction or substance use, domestic violence or primary language if applicable).

Thank you for filling out this match form. Your buddy will be in touch with you soon!

If you require immediate assistance or have concerns about your baby's health, please contact your health care provider. This service is not intended to replace medical care or crisis support.