PERSONAL

How far along are you in your pregnancy:__________________________

Name:__________________________________________________________Date:______________ 			

Current Address:_________________________________________________________________________________ 											

Birth date:_______

Due Date:  _______

Phone:_________________ Social Security No.:___________________				
________________________________________________________________________________________________________

Department of Public Assistance ("DPA") 

DPA Number:_______________

Caseworker:______________________________________________ 
							
Do you have any other caseworker or counselor?_________  No,
 
Name:____________________Agency:_________________________________________________________________ 				

Address:_________________________________________________________________________________________ 								

List any government programs you are on and the amount of assistance you 
receive on the back of this page.
_______________________________________________________________________________________________________

Current Income: $________________  Source: _______________________ 	

Specify: _________________________________________________________

				
What are your favorite hobbie? _______________________________________________________________________

__________________________________________________________________________________________________

EDUCATION/VOCATION
Present or last high school attended:____________________________________________________________ 								

Address:_________________________________________________________________________________________ 												

Dates attended:_________________________________________ Last grade completed:___________________ 			

If you left school at what age did you leave?  __________

Last grade completed: ___________________			

Reason for leaving: ____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________										

Have you received any schooling other than high school? ________ Yes ___________ No

If so, name of institution:______________________________________________________________________ 					

Course of study: ______________________________

Dates attended:________________________________

____________________________________________________________________________________________

YOUR LIVING SITUATION
List the people currently living in your household:__________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________
																				
PARENTS
Father's name: ________________________________ Mother's Name: __________________________________				

Address: ______________________________________ Address: ________________________________________					

Phone:  Home (_____)___________________________	Phone: Home (____) ______________________________			

Work: _________________________________________ Work:____________________________________________ 						

Employer:______________________________________	Employer: _______________________________________ 					


Are your natural parents (check appropriate box):
_____ married and living together ____ separated _____ married not living together
_____ divorced	_____ deceased (which parent? ____________________)

If your natural parents are not living together, how long have they been apart?__________________

Have either of your parents:	_____ remarried? 

_____ lived with another partner?

Stepfather's name: _____________________________________________________
											
Stepmother's name: _____________________________________________________ 											
 
List names and address of your brothers and sisters. (including step and half)

Name			Age	Sex	Address
			
___________________________________________________________________________________________________

___________________________________________________________________________________________________		
			
___________________________________________________________________________________________________
			
___________________________________________________________________________________________________			

What are you doing now? ____ school ____ training program ____ job
 _____ other (specify)

Name of school or employer: _______________________________________________________________________									

Address: __________________________________________________________________________________________ 												

Course of study or position: ______________________________________________________________________ 										

Do you plan to continue your education or receive any more training at the 
present time?
	________ yes		________ no			________ don't know

I plan to study ______________________________________________________________________________ 						

What is your educational goal?




What is your vocational goal?




Do you have any children?

YOUR CHILD(REN) (Fill out only if applicable)
Name: _________________________________________________________	Birth date: 				

Social Security No.: __________________________________________	DPA No. __________________________ 				

CHILD CARE

Who will be caring for your child(ren) while you are a resident at WCCH?

Name: 	 Phone: 			
Address: 					
__________________________________________________________________________________________________

RELIGIOUS BACKGROUND
From what religious background do you come?_______________________________________________________ 							

Are you currently attending church? _____ Yes _____ No

What is the name of the church? __________________________________________________________________ 									

If you are not currently attending church, what religious or denominational 
preference would you have?



____________________________________________________________________________________________


Why are you interested in moving into our household?




How did you find out about our program?




What things about yourself do you want to change or improve?






Do you realize this will be a structured environment including educational,
parenting,and Life skills goals? 
   
			_______Yes  _______NO


 

If you are approved you will be asked to read our Residient Handbook and abide 
by the policies set forth in it.  If a resident is unable to abide 
by the policies in the handbook, they may be asked to leave the center.


Do you believe this will present a problem to you?
	



      WOMEN'S CARE CENTER OF THE HEARTLAND

RESIDENT APPLICATION QUESTIONNAIRE

 					

Applicants Name:  ______________________________________________

Your children's names & ages:   Current address where you receive mail.




Phone: _____________________________________


___________________________________________________________________________________________


FAMILY

Please write a paragraph concerning your relationship with 
your parents.






Please write a paragraph concerning your relationship with 
your brothers and sisters.






CHILD'S FATHER
Please give the full name and the age of the father of the baby:





How did he feel about the pregnancy and what are his feelings now?




What is your relationship with him at the present time?




Does he know you are thinking about coming to our home? 		Yes  		No

__________________________________________________________________________________________

RELIGIOUS
How active have you been in church, if at all ? What are your 
general feelings about religion and God? 








MEDICAL
Please list any previous pregnancies and describe what happened:
Include the due date and, if you had an abortion, when that occurred.




What is your due date?   _____________________

Where do you plan to deliver?  ________________________________

Do you have any serious health problems/conditions?



Are you able to go up and down stairs unassisted?


Have you ever received counseling or therapy?   If yes, what was the
reason for the counseling/therapy?




Please write a paragraph about your tobacco use.



If you have used tobacco, why did you decide to try it?    If you 
have quit using tobacco, what made you decide to stop?






Please give a list of all the drugs you have used, how often
you used them and the last time that you had them.





If you have used drugs why did you decide to try to take drugs? 
If you have quit taking them, why did you decide to stop?






 Please write a paragraph about your use of alcohol. Include 
how often and the last time you had a drink.







If you have used alcohol, what made you decide to use it? 




Have you ever been a victim of abuse?




Why do you want to come here ?




What are some things about yourself that you would like to change
or improve?





What are some goals you have for yourself and your child?



 




REFERENCES

List three people who know you well. You may name one relative. 
Please include your social worker or school counselor if 
they have worked with you in the past two years. Give complete 
mailing addresses.

1.	Name:______________________________________	Phone: _______________

	Address:_____________________________________________________________

	City, State, Zip:________________________________________________________