Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you feel safe where you are right now? *

Yes

A little

No

Phone *

(###)

###

####

Is this your phone number? *

Yes

No

Are you a legal resident of the US?

Yes

No

Other

Have you applied to Grace Home before? *

Yes

No

Unknown

Has your pregnancy been confirmed? *

No

Through a home pregnancy test

By a doctor

With an ultrasound

Date of last menstrual cycle *

MM

DD

YYYY

Approximate due date

MM

DD

YYYY

What do you plan to do once your child is born?

Parent

Adoption

Undecided

Are you involved with DHS? *

Yes

No

Have you ever lived in a group home before? *

Yes

No

Do you have any of the following (Check all that apply) *

Bank Account

Social Security Card

Birth Certificate

State Issued ID

Driver's License

Vehicle

SNAP (Foodstamps)

WIC

Health Insurance

Sooner Care

SSI/Disability

How do you currently support yourself? (Check all that apply) *

Employed

SSI/Disability

SNAP (Foodstamps)

Other

Have you ever been: *

Check all That Apply

Questioned or charged for physical violence‎

Required to register as a sex offender‎

Associated with a gang

Questioned or charged with the possession or sale of illegal or

None of the Following

Have you been arrested? *

Yes

No

Do you have any pending court dates *

Yes

No

Do you report to a probation officer? *

Yes

No

Are you taking regular medications (OTC or Prescription)? *

Yes

No

Have you ever taken illegal drugs?

Yes

No

Have you been diagnosed with any of the following? (Check all that apply)

Major Depression

Anxiety/PTSD

Bipolar Disorder

Eating Disorder

Schizophrenia‎

Personality Disorder‎

Aspergers/Autism/PDD‎

Learning Disabilities

Other

None