Name
*
First Name
Last Name
Age
*
Birthdate
*
MM
DD
YYYY
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Current Living Situation
*
Choose One:
Staying with Friends
Staying with Family
Shelter
Own Place
With boyfriend or spouse
Jail
On the streets
Hospital or treatment facility
Do you feel safe where you are right now?
*
Yes
A little
No
What has you considering a change in your living situation?
Phone
*
(###)
###
####
Is this your phone number?
*
Yes
No
Email Address
Are you currently
*
Choose One:
Single
Engaged
Married
Separated
Divorced
Ethnicity
Choose One:
Black
Caucasian
Hispanic
Native American
Asian
Bi-Racial
Other
Are you a legal resident of the US?
Yes
No
Other
Height
Weight
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
Have you been receiving prenatal care? If Yes where?
What number pregnancy is this for you?
Do you have insurance or Sooner Care? If so, what do you have?
What do you plan to do once your child is born?
Parent
Adoption
Undecided
Name of the baby's father?
*
Where is he currently living?
*
Do you have any other children?
*
Choose One:
No this is my first
Yes in my custody
Yes they are in DHS custody
Yes they are living with someone else
If the children are with someone else please explain
Are you involved with DHS?
*
Yes
No
If Yes, please explain
Have you ever lived in a group home before?
*
Yes
No
If yes, please explain:
What are some of your personal strengths?
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
Highest Level of Education
*
Choose One:
GED
High School Diploma
Some College
College Degree
None of the Above
Other
Learning disadvantages or disabilities (as applicable)
Do your future plans include any educational goals? If so, what are these?
How do you currently support yourself? (Check all that apply)
*
Employed
SSI/Disability
SNAP (Foodstamps)
Other
If other, please explain:
Please list most current employer
How long did you work here?
Choose One:
Still Employed
More Than a Year
6 Months
3 Months
Less Than 1 Month
If no longer employed, why did you leave?
List other jobs that you have held
Please describe your relationship with Mother
Please describe your relationship with your Father
Support Person(s)
Who are people in your life who support and help you?
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
If yes, please explain and include dates and locations
Do you report to a probation officer?
*
Yes
No
If Yes, please explain
Are you taking regular medications (OTC or Prescription)?
*
Yes
No
If yes, please list drugs and what they are for
*
Please list any medical conditions it would be important for us to know about?
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
If Other, please explain:
Why are you interested in coming to Grace Home?
*
What are some questions you have about coming to Grace Home?
How did you hear about Grace Home?
*
Friend/Relative
Support Person
Internet Search
Through Pregnancy Resource Center
Through another agency
Other
I have answered these questions honestly and to the best of my ability. Enter Full Name *
*