Online Self-Referral Form

One of the primary goals of this community-based effort is to improve health among African-American families, mothers, and babies. We have created a process to help you better access programs available to you.

Please complete the brief form below to access some community resources, including Baby Cafes (breastfeeding support), the Baby and Me Tobacco Free program, and food pantries. When you complete the form, you will receive a confirmation email that someone from the Gulf Coast Healthy Families, Mothers, and Babies team will contact you to connect you to the services needed. This program is currently for individuals residing in Harrison, Hancock, or Jackson County.

If you have any questions or need any additional information about the services and support we can offer, please contact Ruby Montgomery at 228-864-0003 ext. 1071.