WarmLine Call Form(Printable Version)
Thank you for making a difference in the life of a child.

  (You can fill out this form and print it or just print a blank form.)   (For the Online FormCLICK HERE)


Fields marked with an * are required

Information about Caller:
*Caller's Name:  
*Phone #  
Address:
City: Zip code:
*Volunteer:  

Call Date:          

*Month: *Day:
 *Year:     *Shift:

Regular Shift?Direct CallCall Back
Substitute?Spanish Call?Email

Time call received:   (HH:MM)  
Time call returned:   (HH:MM)  
Length of call:   (H:Min)  
How did Caller hear about WarmLine?  (Select all that apply)
TV commercialFamily Member FriendPhone BookKern County Family Magazine
Parent WiseMaiin Street MarketplaceFlyer, what color?Previous Caller
Call BackMagnetOtherUnknown
Child's Name:  Age:  Siblings and Ages:

Caller's Main Concern:

Describe the Call:

Specify your recommendations, suggestions, impressions, services offered:

 

Referrals: Margaret Gannon (661) 323-0055
Drop-in Appt. Date: Appt. Time
Reminder Call:YesNo   Follow-up Call:YesNo
Possible child abuse (report to Margaret)
Send Materials: see list below

Caller Demographics:

Gender:
Male
Female
Call taken in:
English
Spanish
Ethnicity:
Caucasian
African-American
 
Hispanic
Asian-American
Unknown
Marital Status:
Married
Single
Divorced
Unknown
Family Type:
Traditional
Blended
Single Parent
Unknown
Foster
Call made by:
Mother
Stay-at-home-Mom
Step Mom
Working Mom
Teen Mom

Father
Grandmother
Other Relative
Childcare Worker
Preschool/ K.Teacher

Community Professional
Other
 

   

The Following Parent Educational Materials are available to send to callers
(Check all Requested Materials)

 

General:
10 Tips for a Single Parent
Building Child's Self-esteem
Feeling Good About Yourself as a Parent
Mom's Group List
Ten Tips on How to Talk to your Child
What is a Good Parent?

Pregnancy; Labor & Delivery:
Bedrest in Pregnancy
Doulas:10 Great Reasons to have a Doula @ Your Birth
Just the facts about Episiotomy
Just the facts about inducing & Augmenting Labor
Labor Support-A quick guide for birth partners
Loss of a child
Maternal Fitness Workout
Miscarriage
Newborn Screening Test
Overcoming 10 myths on Teen Pregnancy & Parenting
Prenatal Perineal Massage
Sex during Pregnancy
Shake, Rattle, & Roll: Counting Babies Movements
Ten Tips on Comfort Measures for Labor & Delivery
Ten Tips on Eating Right While Pregnant
Turning a Breech Baby to Vertex
VBAC (Vaginal Birth After C-Section)
 

Post Partum & Infants:
Babies & Jobs: Concerns and Choices
Baby's First Weeks
Breaking the Silence, Depression around Childbirth
Breastfeeding Comfort Line Brochure (1-800-400-0655)
Car Seat Safety
Coping with Crying and Colic
Formula vs. Breastmilk
Going Home... 10th Month taking Care of Mom
I Am Your Child
Is Your Little One on Track
Preventing Baby Bottle Tooth Decay
Sex After Baby Comes
Shaken Baby Syndrome
 


Siblings, Birth, and Newborns
So, you Have Just Gotten a Cesarean
Starting Your Baby on Solids
Step-By-Step: As Your Child Grows (2mos. - 24mos.)
Sudden Infant Death Syndrome (SIDS)
Ten Tips on How Dad Can Help with the Baby
Ten tips on keeping your Baby Safe
Ten Tips: Help Your Baby Grow and Learn
Ten Ways to Help Your Infant's Brain Develop
The 1st days After Birth: Care of Mommy and Baby
The importance of Attachment
The Neglected Disorder: Postpartum depression
Your Infant's Brain development


Toddlers & Preschoolers:
Children's Behavior: Why Won't My Child Behave?
Dealing w/ "Bad" Behavior: Biting, Hitting, Hair Pulling
Discipline Your child
Getting Your Little One to Bed
Helping children deal With the New Baby
How to Find Good Child Care
Nightmares & Night Terrors
Poison Proofing Your Home
Preparing Healthy Snacks
Rewarding Children without Food
Separation: It is Hard to say Goodbye
Shopping with Children
Temper tantrums
Ten Tips on Feeding Your Toddler w/o fuss
Ten Tips on Raising Kids w/o Physical Punishment
Ten Tips on toilet Training Your Toddler
The Importance of Play for Young children
The Importance of Reading to Your Child
Think Before You Spank
Tips for Picky eaters
Toilet Mastery
 

School -Age Children:
Discipline for School - Age children
Ten Tips on Discipline for School - Age children
 
 
Office Use
Code:____________________
Sent Materials
Entered into Computer
Answering Service Call Log