Referral Form

Our goal is to ensure Moms, caregivers, and families feel welcome, without judgment, at Jacob’s Hope. Please fill out our online referral and our team will make contact as soon as possible.

You Are Safe Here

Asking for help is an act of love and we are so proud of you. You are not being judged, and you are not in trouble. Share only what you’re comfortable with. We’re here to support you and your baby.

About the Mother

Mother's Name(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY

Optional (but helpful for referral/intake process)

Fill out as much as you are willing and able to do.
Currently in Medically Assisted Treatment (MAT) Program?
Does mother have AHCCCS?
Does mother have OB care?
Resources needed:

How Can We Reach You?

Your Name *(Required)

Our Facility

modern comfortable medical facility interior, welcoming peaceful environment, soft lighting

Our facility is an inpatient, home-like setting.

  • Sensory friendly, calm, and quiet environment.
  • 24-hour medical staff on site providing individualized care.
  • Medically equipped facility to meet infant needs.
  • Volunteer Baby Cuddlers

Change a life today

It doesn’t take much to change a life, Get in touch today and start making the difference.

The King will reply, “Truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me.”

– Matthew 25:40

Visit Us

1150 N. Country Club Dr., Unit 12 Mesa, AZ 85201

Call Us

(480) 398-7373

We're Here

24/7 Care Available

Additional Support Resources

We partner with trusted organizations to provide comprehensive support

Crisis Support

Immediate help available 24/7 for moms in crisis or needing urgent support

Housing Assistance

Connections to safe, stable housing options for moms and families

Legal Advocacy

Support navigating DCS cases and understanding your parental rights

Stories of Hope

Real stories from moms who found support at Jacob’s Hope

Sarah

Sarah M.

Phoenix, AZ

“I was terrified to reach out, but Jacob’s Hope treated me with so much kindness. They helped me understand what my baby needed and supported me every step of the way. I’m so grateful I found them.”

Maria L.

Tucson, AZ

“The staff at Jacob’s Hope never made me feel like a bad mom. They gave me tools and resources I didn’t know existed. Now my baby is thriving and we’re building a better life together.”

Frequently Asked Questions

Quick answers to common questions about the referral process

What happens after I submit a referral?

A member of our team will contact you within 24-48 hours to discuss your needs, answer questions, and explain next steps. There’s no pressure—just support.

Can I refer someone else?

Yes. If you’re a family member, friend, or healthcare provider, you can fill out this form on behalf of a mom who needs support. We’ll reach out with compassion and respect.

Is my information kept confidential?

Yes. We take privacy seriously and handle all information with strict confidentiality in accordance with HIPAA and other privacy laws.

Do I have to fill out every field?

No. Fields marked with an asterisk (*) are required, but everything else is optional. Share only what you’re comfortable sharing. We’ll work with whatever information you provide.

What if I’m not sure I need help yet?

That’s okay. Filling out a referral doesn’t commit you to anything. It simply opens the door to a conversation. You can ask questions, learn about options, and decide what feels right for you and your baby.

Need Immediate Help?

If you or your baby are in immediate danger or experiencing a medical emergency, please call 911 or go to your nearest emergency room.

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