Client’s Name: ______________________________Client #:________ DOB: ___________Date: _____________
NEW CLIENT INTAKE
Welcome Baby Bridges Screening Matrix for Mothers and their Newborns
Risk Level
1. Mother’s age: __________
Race/Ethnicity: ______________
Country of Birth: ____________
Time in USA (yrs): ___________
None
Low
Moderate
High
25- 39
20-24
17-19 or over 39
Under 17
4
8
12
0
2. Mother’s use of English
Fluent
0
Medium Fluency
1
Some English
2
No English
3
3. Mother’s highest education
level:
College
Graduate
0
Some
College
3
High school or GED
Did not complete high
school
9
4. Mother’s marital status
Married
Single with roommate
4
0
Single, living w/
partner/family
2
FT
PT
Self-Employed
Temporary
6. Annual household income
level:
$_____________________
>$60,000
$60K-36K
$36K-18K
0
3
6
Below $18K or mother
unaware of income
9
7. Health Coverage
Full
Temporary (i.e.
restricted; pregnancy
only, AIM)
2
None
0
Partial
(i.e. hospital only;
high deductible)
1
Consistent
Adequate
Inconsistent
0
3
6
Chronically
inadequate
9
Full Awareness
Moderate Awareness
Some Awareness
No Awareness
0
1
2
3
Never
0
Rarely
1
Sometimes
2
Frequently
3
Family and/or partner is
supportive, available and
committed to help
Inconsistent or
limited family or
partner support (e.g.,
family is supportive
but partner is not)
Family or partner
supportive but not in
geographic area; some
support from friends
and neighbors; limited
community services
available
No relatives/friends/
partner available or
committed;
geographically
isolated from
community services;
no phone
0
2
4
6
5. Employed:
Y
N
Dental care?
Y
N
8. Adequate food in the house
9. Mother’s demonstrated
awareness of available
resources
6
Single, living alone
6
3
Public Benefits:
CW FS WIC HA SSI GR
10. Transportation a barrier?
11. Level of family support
Secondary Caregiver Info:
Name: _____________________
Relationship to NB: __________
Employed:
Y
N
FT
PT
SE
Temp
Help w/baby once home: Y
N
SC present during birth: Y
N
12. Other Children @ Home
Name
None under 5 y/o;
singleton birth
1-2 under 5 y/o;
singleton birth
First-time mother or 0-2
under 5 y/o w/twin or
multiple
birth
0
1
2
Stable and safe
Adequate
Rents a motel, garage or
portion of a living space;
frequent migration;
staying with friends
Currently homeless or
in temporary shelter or
car
12
18
Household members
smoke
2
Mother smokes
Age
13. Current housing conditions
0
14. Tobacco smoke in home?
6
No smoking
Visitors smoke
0
1
15. Adequate and timely
PNC?
Accessed PNC w/in 3
months; consistent with
follow up appts
Month/Year initiated PNC:
___________________
0
Accessed PNC
between 3 and 6
months; consistent
with follow up
appts
4
Did not access PNC until
after 6 months or
inconsistent with f/u
appts
3 or more under 5 y/o
w/ singleton, or
multiples, or other
child(ren)removed
from home or
deceased
3
3
No PNC
8
12
NB enrollment faxed
by WB?
Y
N
Infant present during
PPHV?
Y
N
Why not? __________
Was baby in
NICU?
Y
N
Rooming In?
17. Infants’ Health Coverage
Full
0
Partial
1
Temporary
2
None
3
18. Source of medical care
Infant’s PCP:
_________________________
Regular pediatrician or
community clinic
0
Attending
pediatrician
1
Emergency room
No plan for future care
3
Very Strong
Moderately Strong
1
Weak
16. Infants Information:
Name:
____________________________
Y
N
2
F/U appts scheduled:
Y
N
19. Mother’s intent to remain
current with well-baby
care and immunizations
for her infant
0
2
Very Weak/
No Understanding
3
No apparent medical or
physical problems
Minor medical or
physical problems
which do not
significantly affect
infant’s vital
functions or
physical and
intellectual
development
(including low
Apgar score)
Medical or physical
problems which
moderately affect
infant’s vital functions or
physical and intellectual
development
0
6
12
How long Clt wants to BF: _____
Not
Worried
0
Mother demonstrates
knowledge, confidence
regarding infant feeding;
sufficient resources
available to support a
healthy feeding
relationship with infant
Moderate
Worries
2
Great uncertainty or lack
of experience or
knowledge with infant
feeding and/or limited
resources available to
support a healthy feeding
relationship
BF education/support: Y
Minor
Worries
1
Mother requires
some education
regarding infant
feeding; adequate
resources available
to support a healthy
feeding
relationship
0
20. Infant’s Medical Problems
Any birth complications?
21. Mother’s worry about
infant’s health
22. Infant Feeding Issues:
B
MB
MF
FF
N
3
BF assistance:
Y
___ Latch/Positioning
___ Pumping
___ Engorgement
___Sore Nipples
___ Milk Supply
N
Any pre-term infant
(born at or before
36weeks) and/or
physical or medical
problem which
significantly impacts
vital life functions or
physical and
intellectual
development (e.g.,
cardiac defect, apnea,
visual or hearing
handicap, seizure
disorder)
18
Very
Worried
3
Grossly insufficient
knowledge regarding
infant feeding; lack of
interest in improving
feeding skills;
evidence of or high
potential for poor
feeding relationship
with infant
9
6
At least 1 hr of Skin to Skin:
___Yes, right after birth
___Yes, the first day
___Not at all
___N/A (NICU, emergency, etc)
23. Strength of maternal bond
w/infant?
Strong
0
Moderate
5
Weak
10
None
15
24. Medical Problem
No limitations; fully
able to care for child
0
Mild limitations
which may impact
ability to care for
child
6
Moderate limitations
which could significantly
impact ability to care for
child
12
Severe limitations;
mother is unlikely to
be able to care for
child
18
25. Mental Health Problem
(Mother; include PPD)
No limitations; realistic
expectations of child; in
full control of mental
faculties
0
Mild limitations
which may impact
ability to care for
child
6
Moderate limitations
which could significantly
impact ability to care for
child
12
PHQ2 completed?
Y
N
PHQ9 completed?
Y
N
Score:___________
Severe limitations;
mother is unlikely to
be able to care for
child
18
26. History of domestic
violence?
27. History of child
abuse/neglect?
No known history of
domestic violence
No low level for
this category
Partner currently in
treatment for domestic
violence.
0
0
12
No known history of
child abuse/neglect
No low level for
this category
Prior protective services
provided to siblings,
with that episode
resolved and case closed;
mother retains custody
of siblings; parent of
child was a victim of
childhood abuse.
0
0
No
History
Some history but
not currently using
any drugs/alcohol
Mother/Father/Significan
t Other is receiving
drug/alcohol treatment,
remains in program, and
is considered compliant
6
12
Include parents’ own
childhood history of abuse
or any non-spousal assault
History of incarceration for
mother, partner or by people
who will impact infant’s
wellbeing?
Mother: Y N
Partner Y N
Other: Y N
28. History of excessive alcohol
or other drug use by people
who will impact infant’s
wellbeing?1
Domestic violence
investigation; previous
domestic violence of
serious nature; prior
court action
18
Pending child
abuse/neglect
investigation; previous
abuse/neglect; prior
court action, e.g.,
siblings removed from
home; or child abuse
suspected or discussed
but no system
intervention to date
18
12
0
Alcohol/drug use includes: use of illegal substances or alcohol, misuse of prescription drugs or non-prescription substances.
Medical Score
Psycho-social Score
Demographics/Basic Needs
Total Bridges Score
 Needs further breastfeeding assistance/support (yes/no)
 Referred to Social Worker (yes/no)
Recommended Follow-up:
Welcome Baby
Intensive Home Visitation
Unsure
If Unsure:
[Text box]:
Mother/Father/Signific
ant Other not in
drug/alcohol treatment
program; individual is
in program but
attendance is sporadic;
(mother) entered
program late in
pregnancy
18