Complete the intake form to apply for Lori’s House. * = required Age: *Marital Status: SingleMarriedDivorcedEngagedSeparated *Do you have a valid driver's license? YesNo *Do you own a car? YesNo In your name? YesNo Is it paid off? YesNo Do you have car insurance? YesNo Section 1 1) *Are you currently pregnant? YesNo 2) How many weeks pregnant are you? 3) 4) 5) 6) 7) 8) Are you having a boy or girl? UnsureBoyGirlBoth Section 2 1) *Are you receiving WIC at this time? YesNo 2) *Are you on any type of government assistance? YesNo 3) *What type of insurance do you have? NoneMedicaidMedicarePrivateMedical AssistanceVAOther If you answered "other", please list your provider: Section 3 1) *Do you have any of the following? Mental Health Issues YesNo Drug Issues YesNo Alcohol Issues YesNo Asthma YesNo Diabetes YesNo Allergies YesNo Developmental Disability YesNo Physical Disability YesNo HIV/AIDS YesNo Victim of Domestic Violence YesNo Chronically Mentally Ill YesNo Special Needs YesNo Unspecified Disability YesNo Communicable Illness YesNo ? Tuberculosis YesNo Learning Disability YesNo Lupus YesNo Attention Deficit Disorder YesNo 2) *Are you on medication? YesNo 3) *Do you have any other health problems? YesNo 4) *Are there any emotional problems in your family? YesNo 5) *Is there a history of drug or alcohol abuse in your family? YesNo 6) *Have you used: Alcohol YesNo Marijuana YesNo Cocaine/Crack YesNo Heroin YesNo Meth YesNo Prescription Drugs YesNo Pain Killers YesNo 7) *Do you smoke? YesNo Section 4 Do you know who your baby's father is? YesNo Does he know you are pregnant? YesNo Does he have a history of drug use? YesNo Have you used drugs together? YesNo Does he own a weapon? YesNo Has he ever threatened you? YesNo Has he ever threatened others? YesNo Section 5 *Have you been pregnant before? YesNo If "yes" how many times? *Do you have any children? YesNo Children Info: Age: Gender: ChooseMaleFemale Age: Gender: ChooseMaleFemale Age: Gender: ChooseMaleFemale Age: Gender: ChooseMaleFemale Age: Gender: ChooseMaleFemale Section 6 *Have you experienced physical, emotional, or verbal abuse? YesNo *Have you experienced sexual abuse? YesNo Is your family aware of this? YesNo *Have you ever sought counseling? YesNo *Are you in danger? YesNo Section 7 *Are you currently under court authority, including DFS, for any reason? YesNo *Are you on probation or parole? YesNo *Do you have any pending charges? YesNo *Do you have any prior convictions? YesNo *I acknowledge that I will have to pass a background check before I am accepted into Lori's House. Section 8 Legal Name I prefer to be called Today's Date Phone Number Email Address Referral Name and Relationship Currently Staying... Location: State/City and Place What is the relationship/atmosphere of your current location? How long have you been there? How long can you stay? What are your options? Birthdate Current Age Place of Birth Citizenship Race Social Security Number Marital Status Do you own or have a vehicle? Do you have a valid and current Driver's License? Do you have car insurance? Do you have any ongoing financial responsibilities? Please list them all and explain amount/balances... How will you continue to pay those while in the program? What governmental assistance are you on? (WIC, Foodstamps, Medical) Do you have any other insurance? My social media account (facebook/insta/snapchat/tikt,twitter) Are you currently pregnant? Are you currently pregnant? Yes No Unsure How many weeks are you? When is your expected Due Date? Have you seen a doctor? Have you seen a doctor? Yes No What was the date of your last prenatal Dr appt? Dr Name and Location Are you having a boy or girl? Are you having a boy or girl? Boy Girl Still Unknown Do you know who the Father is? Do you know who the Father is? Certain Most Likely Possibly Very Unsure No Idea Baby's Father's Name Does He know you're pregnant? Whereabouts How does he feel about it? How did you meet? Check all that Apply Check all that Apply We are committed to each other We want to eventually get married Im not sure how he feels We talk all the time We rarely talk There is no relationship Describe him (personality/job/traits) Describe your relationship with him How long have you known him? Check all that Apply Check all that Apply He has a history of drugs We have used drugs together He owns weapons He has threatened me He has threatened others Check all that Apply to your Family Check all that Apply to your Family I have support from my family I do not get along with my family My family has no resources to help me We talk all the time We rarely talk There is no relationship Explain your relationship with your mother currently Explain your relationship with your father currently Where is your family? Explain any issues, abuse or problems with your family Have you been pregnant before? Have you been pregnant before? Yes, I have other children with me Yes, I share custody Yes, but I do not have them currently Yes, but do not have any children (failed pregnancies) No, this is my first How many children have you birthed? How many times have you been pregnant? Please list all your children's names (current location, age, date of birth, gender and who has legal custody of them) Please list all your children in your care (with you) Please explain any needs/issues or continual learning challenges of the children in your care Which apply to schooling for the kids in your care? Which apply to schooling for the kids in your care? My kids are enrolled in school already, I want them to stay there My kids will need to enroll in school there My kids are enrolled in preschool or daycare I homeschool my kids None of the Above Health Questions: Check all that you've had/have Health Questions: Check all that you've had/have Mental Health Issues Drug Use/Abuse Alcohol Use/Abuse Prescription Drug Abuse Asthma Blood Disorders Diabetes Allergies Disabilities HIV/AIDS Miscarriages Smoking List all Medications you are currently on/how long Have you used Alcohol, Smoking or Vapes? Have you used Alcohol, Smoking or Vapes? Yes No First Time You Used Last Time You Used Tell us your history of all the above Do you understand there is no tolerance or allowance of drinking or smoking of any kind during the program? Do you understand there is no tolerance or allowance of drinking or smoking of any kind during the program? Yes No Have you used any drugs (Such as but not limited to: weed, cocaine, heroin, meth, pain killers) Have you used any drugs (Such as but not limited to: weed, cocaine, heroin, meth, pain killers) Yes No First Time You Used Last Time You Used Tell us your history of all the above Do you understand there is no tolerance or allowance of any drugs during the program? Do you understand there is no tolerance or allowance of any drugs during the program? Yes No Explain any history of physical, sexual, emotional or verbal abuse Have you had counseling? Have you had counseling? Yes No Are you or your baby in any danger? If so, please explain by whom and the situation Explain any/all court orders, DFS, probations, convictions, parole or charges Check all that apply Check all that apply Domestic Violence Mental Illness Special Needs Disability Communicable Illness Tuberculosis Lupus ADD How do you deal with conflicts, anger or miscommunications Explain how you cope/or don't cope with authority What are your views on Christianity/God Do you acknowledge that we will run a background check on you? Do you acknowledge that we will run a background check on you? Yes No Explain how you're ready for change 3 + 4 = Submit
