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Pregnant?
Your Options
Abortion
Adoption
Parenting
Our Services
Pregnancy Tests
Referrals
The HOPE Program
Parenting Classes
Spiritual Help
Amazing Grace Home
FAQ
Blog
Contact
AGH Application
Name
(Required)
Age
(Required)
Birth Date
(Required)
MM slash DD slash YYYY
Contact Number
(Required)
Leave Message
(Required)
Yes
No
Address
(Required)
Present Address
City
State
Zip
Is this your permanent address?
(Required)
No
Yes
Marital Status
(Required)
Married
Single
Widowed
Divorced
Previous Housing
Please list the last place you have lived other than your present address.
Name
Phone Number
Relationship
Add
Remove
Please list the last place you have lived other than your present address.
Address
Cit, State, Zip
Length of stay
Add
Remove
How did you come to know about us?
(Required)
Why would you like to come to the Amazing Grace Home?
(Required)
Pregnancy and Parenting Information
What is your pregnancy due date?
(Required)
Are you currently parenting other children?
(Required)
No
Yes
# of Children
Do you have children who are not currently in your custody?
(Required)
No
Yes
# of Children
Employment & Financial Situation
Currently working?
(Required)
No
Yes
If yes, please explain.
Full-Times / Hours a Week
(Required)
Part-Time / Hours a Week
(Required)
Shift Hours
(Required)
Job Title & Description
(Required)
Hourly Wage
(Required)
Start Date
(Required)
Move List Two Previous Employers
(Required)
Company Name
Job Title
PT or FT
Time Employed
Reason for Leaving
Add
Remove
Move Last Two Previous Employers
(Required)
Company Name
Job Title
PT or FT
Time Employed
Reason for Leaving
Add
Remove
Do you receive other income?
(Required)
No
Yes
If yes, please explain.
How do you plan to support yourself during maternity leave?
(Required)
Medical/Emotional/Spiritual Health
Receiving Medical Care?
(Required)
No
Yes
Doctor
(Required)
Clinic
(Required)
Do you have Medical Insurance?
(Required)
No
Yes
Name
(Required)
Policy Number
(Required)
Do you have special medical needs or diet?
(Required)
No
Yes
If yes, please explain.
Are you currently receiving mental health care?
(Required)
No
Yes
Where?
(Required)
Have you received mental health care in the past?
(Required)
No
Yes
Where?
(Required)
Are you currently attending a church?
(Required)
No
Yes
Where?
What are your general feelings about religion and God?
(Required)
Relationships
Baby’s Father First Name:
Age
Does he know about the pregnancy?
(Required)
No
Yes
If yes, how has he reacted to your pregnancy?
Has he offered to help you?
(Required)
No
Yes
If yes, how has he offered to help?
How does he feel about coming to our home?
(Required)
What kind of contact do you expect to have with him during your stay at AGH?
(Required)
Boyfriend: If you are involved with a person, other than the father of the baby, please describe your relationship to him. What are his feelings about your pregnancy and about you coming to our home?
(Required)
Education
Name of High School and Graduation Year
(Required)
Dropped out?
(Required)
No
Yes
If you are currently in school, please list school and program.
(Required)
Legal History
Have you ever been involved with law enforcement?
(Required)
No
Yes
Reason
Please explain any past and/or current legal involvement (i.e., divorce, domestic abuse issues, probation, child protection involvement, etc.)
(Required)
Are you currently using recreational drugs and/or alcohol?
(Required)
No
Yes
If yes, please list.
Have you used recreational drugs and/or alcohol in the past?
(Required)
No
Yes
If yes, please list.
Applicant Signature
Date
MM slash DD slash YYYY
Comments
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