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







    Are you currently pregnant?

    Have you seen a doctor?

    Are you having a boy or girl?

    Do you know who the Father is?

    Check all that Apply

    Check all that Apply

    Check all that Apply to your Family

    Have you been pregnant before?

    Which apply to schooling for the kids in your care?

    Health Questions: Check all that you've had/have

    Have you used Alcohol, Smoking or Vapes?

    Do you understand there is no tolerance or allowance of drinking or smoking of any kind during the program?

    Have you used any drugs (Such as but not limited to: weed, cocaine, heroin, meth, pain killers)

    Do you understand there is no tolerance or allowance of any drugs during the program?

    Have you had counseling?

    Check all that apply

    Do you acknowledge that we will run a background check on you?

    3 + 4 =

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