Online Intake Application Form

Complete the intake form to apply for Lori’s House.

* = required

Age:

*Marital Status:

*Do you have a valid driver's license?

*Do you own a car?

In your name?

Is it paid off?

Do you have car insurance?

Section 1

1) *Are you currently pregnant?

2) How many weeks pregnant are you?

3)

4)

5)

6)

7)

8) Are you having a boy or girl?

Section 2

1) *Are you receiving WIC at this time?

2) *Are you on any type of government assistance?

3) *What type of insurance do you have?

If you answered "other", please list your provider:

Section 3

1) *Do you have any of the following?

Mental Health Issues

Drug Issues

Alcohol Issues

Asthma

Diabetes

Allergies

Developmental Disability

Physical Disability

HIV/AIDS

Victim of Domestic Violence

Chronically Mentally Ill

Special Needs

Unspecified Disability

Communicable Illness

? Tuberculosis

Learning Disability

Lupus

Attention Deficit Disorder

2) *Are you on medication?

3) *Do you have any other health problems?

4) *Are there any emotional problems in your family?

5) *Is there a history of drug or alcohol abuse in your family?

6) *Have you used:

Alcohol

Marijuana

Cocaine/Crack

Heroin

Meth

Prescription Drugs

Pain Killers

7) *Do you smoke?

Section 4

Do you know who your baby's father is?

Does he know you are pregnant?

Does he have a history of drug use?

Have you used drugs together?

Does he own a weapon?

Has he ever threatened you?

Has he ever threatened others?

Section 5

*Have you been pregnant before?

If "yes" how many times?

*Do you have any children?

Children Info:


Age: Gender:


Age: Gender:


Age: Gender:


Age: Gender:


Age: Gender:

Section 6

*Have you experienced physical, emotional, or verbal abuse?

*Have you experienced sexual abuse?

Is your family aware of this?

*Have you ever sought counseling?

*Are you in danger?

Section 7

*Are you currently under court authority, including DFS, for any reason?

*Are you on probation or parole?

*Do you have any pending charges?

*Do you have any prior convictions?

*I acknowledge that I will have to pass a background check before I am accepted into Lori's House.

Section 8







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