Online Intake Application Form 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
