If you or one of your clients have questions about breastfeeding or are struggling, don’t feel discouraged. Breastfeeding can be challenging, especially as a new parent.
Benton County Public Health is here for every mom, whether choosing to breastfeed, pump or formula feed. We offer the lactation help and support needed to feel empowered in parenting choices.
Please fill out this form and one of our Certified Lactation Counselors (CLC) or Internationally Board-Certified Lactation Consultant (IBCLC) will be in touch to offer the support needed.
** Please note, forms submitted will only be reviewed during business hours. Please contact your health care provider if it is urgent.
How many weeks pregnant?
Please provide any details that may be helpful to the lactation provider. This may include a summary of what was discussed with client.
Our Benton County Public Health Nursing program can
provide information on healthy pregnancies, giving birth, breastfeeding,
parenting and other helpful resources. If you are interested, by selecting
'Yes' below, you are giving the Benton County Public Health your permission to
release and exchange the following information with the nurses from the Benton
County Public Health Nursing Program:
- Information collected about me or my child as
follows: name, date of birth, address and telephone number.
- Information about whether I participate in the WIC
The Benton County Public Health Nurses will use the
information to provide services under those programs if I am eligible and wish
to participate. I understand that I do not have to agree to the release of
information described in this document. I also understand refusing to sign this
authorization will not affect my participation in the WIC Program, will not
affect the current or future care I receive from any health care provider, and
will not cause any penalty or loss of benefits to which I am otherwise
entitled. I may cancel my permission at any time in writing. I understand the
written cancelation will not affect information the agency has already
released, requested, or received. This authorization will expire one year from
I wish to release my information to
the Benton County Public Health Nursing Program:
By checking the
"I agree" box below, you agree and acknowledge that 1) your form will not be signed in the sense of a traditional paper document, 2)
by signing in this alternate manner, you authorize your electronic signature to
be valid and binding upon you to the same force and effect as a handwritten
signature, and 3) you may still be required to provide a traditional signature
at a later date. 4) by signing this form electronically, you are allowing the release of information to the lactation providers on staff.
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
This field is not part of the form submission.
* indicates a required field