In Take Form – Hands Lifting Hearts

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info@handsliftinghearts.ca
Unit 213, 3942 29 Street NE Calgary, Alberta T1Y 6B6

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info@handsliftinghearts.ca
403-836-7097

We offer support and hope to women and families navigating pregnancy and postpartum challenges, while also establishing a platform to address and prevent racism, health inequalities, sexual abuse, and promote the wellbeing of the African, Black, and Carribbean communities in Canada.

Information

Suite 2019E, Heritage Square 8500 Macleod Trail SE Calgary AB T2H 2N1
info@handsliftinghearts.ca
403-836-7097

Information

In Take Form

Intake Form

Your Journey to Compassionate Support Starts Here

Our intake form is the first step in connecting you with our comprehensive range of services, tailored to support you and your family through every stage of your journey. Fill out the form below to help us understand your needs and how we can best support you. Together, we can build a community of care, compassion, and strength.

Become A Volunteer

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African Refugee Crises Food & Health Program

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African Refugee Crises Food & Health Program

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African Refugee Crises Food & Health Program

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African Refugee Crises Food & Health Program

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African Refugee Crises Food & Health Program

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African Refugee Crises Food & Health Program

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African Refugee Crises Food & Health Program

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African Refugee Crises Food & Health Program

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African Refugee Crises Food & Health Program

Hands Lifting Hearts Intake Form

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Phone Number *

Email *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Your Marital status

Marital Status *

Single
Married
Common Law
Seperated
Divorced
Widowed

If Married/common law Are you in Canada with Spouse? *

Yes
No
N/A

Pregnancy Status

Are you pregnant? *

Yes
No
New Mum

If pregnant, are you having. *

Girk
Boy
Multiple
Surprise

How far are you gone in your pregnancy journey (weeks or months)? *

Is this your first Baby. *

Cultural Background (Nationality)

How long have you been in Canada? *

Less than 1 year
1-3 years
Greater than 3 years

What's Your Status? *

Canadian
Permanent Resident
Visitor
Student
Work Permit
Other

Provide us with your status in canada

How can we support you? (check all that apply)

Birth Support
Baby Essentials
Mum Essentials
Meals
Transportation
Connecting to a Dr
Mental Health Support
Village Mums Home Visitation
Other

List other(s) here

Consent

In order to coordinate support, I give Hands Lifting Hearts my consent to share my information with other agencies provided it is deemed in my best interest. *

Yes
No

How did you hear about HLH? If referred. Tell us who. *

Signed *

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Get in touch!

Unit 213, 3942 29 Street NE Calgary, Alberta T1Y 6B6
(403)-836-7097
info@handsliftinghearts.ca

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