In the state of Tennessee, 13% of all women with a recent live birth reported symptom of post-partum depression according to the United Health Foundation (2024). This prevalence is greater in those who identify as a person of color, are under the age of 24, and/or are new to America (refugee/immigrant). ConnectUs Health, an FQHC located in Nashville, TN serves an elevated number of recently immigrated patients, as well as those who live in the surrounding communities, with many of the patients at a higher risk of social and behavioral health needs. This session will provide an in-depth look at the team- based processes that were developed to identify needs, provide resources, and implement interventions early in pregnancy. The team includes Certified Nurse Midwives, a Women's Health Nurse Practitioner, a Behavioral Health Consultant, a Doula, a Psychiatric Mental Health Nurse Practitioner, and Community Resource Navigators who provide care from the first positive pregnancy test up to a year after birth.