Name
*
First Name
Last Name
Email
*
Age
*
Birth Date
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Current Living Situation
*
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 right now?
What has you considering a change in your living situation?
Phone
*
(###)
###
####
Is this your phone number?
*
Relationship Status
*
Ethnicity
*
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 of pregnancy is this for you?
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?
If the children are with someone else, please explain.
Are you involved with DHS?
Yes
No
If you answered yes to the previous question, please explain here.
Have you ever lived in a group home before?
*
Yes
No
If you answered yes to the previous question, please explain here.
What are some of your personal strengths?
Do you have any of the following
*
Check all that apply
Learning disadvantages or disabilities (if applicable)
Do your future plans include any educational goals? If so, what are these?
How do you currently support yourself?
*
Check all that apply
If you selected other in the previous question, please explain here.
Please list most current employer.
How long did you work here?
Still employed
More than a year
6 months
3 months
less than 1 month
Other
If you are no longer employed, why did you leave?
Please list other jobs that you have held.
Please describe your relationship with your mother.
Please describe your relationship with your father.
Who are people in your life who support you and help you?
Support Person(s)
Have you ever been:
*
Check all that apply
Have you been arrested?
*
Yes
No
Do you have any pending court dates?
*
Yes
No
If you answered yes to the previous question, please explain and include dates and locations.
Do you report to a probation officer?
*
Yes
No
If you answered yes to the previous question, please explain.
Are you taking regular medications (OTC or Prescription)?
*
Yes
No
If you answered yes to the previous question, please list the drugs and what they are used for.
Please list any medical conditions that we should be aware of?
Have you ever taken illegal drugs?
Yes
No
If you answered yes to the previous question, please explain here.
Have you been diagnosed with any of the following?
Check all that apply
If you selected other in the previous question, 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 Your Full Name and response here
