T.E.A.M. Mom: Initial Interest Form

Welcome!

Whether you are a young mother or the parent/guardian of the young mother, before you fill this form out, we want you to know that you are not alone! No matter what brings a mother (or her village) to this page, we believe every young mother is worthy of respect, encouragement, and support from a safe community.

T.E.A.M. Mom is a faith-centered community devoted to equipping and uplifting single young mothers between the ages of 13 and 21 who face an unplanned pregnancy. Our mission is to Transform, Empower, Assist, and Mentor single young mothers by giving them the support necessary for reaching their fullest potential.

We look forward to finding out how T.E.A.M Mom can be a resource along your journey.

Once you complete the form, we'll be in touch soon!

T.E.A.M. Mom
Applicant Information

Please complete this section with the information of the participating mother. This form must be completed by either: 1) the parent/guardian of the mother (13-17 years old) or 2) the participating mother (18-21 years old). The information provided will help our team better prepare for a follow up virtual conversation.
Name of Participating Mother*

First NameLast Name
Current Education Level*
Date of Birth*

MonthDayYear
Motherhood Status*

The mother is currently pregnantThe mother already has a child/childrenThe mother already has a child/children and is currently pregnantOther
How did you hear about us?*

Family ReferralFriend ReferralSocial MediaOrganization ReferralGoogle/Internet SearchOther
Parent/Guardian Information

*This section is not required for mothers 18-21 years old, but it still highly recommended.
Name

First NameLast Name
Location (To determine eligibility)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How would you like to arrange the initial follow up session?
Let's Connect!

T.E.A.M. Mom hosts an initial follow up session (virtually) for all potential participants. This gives us an opportunity to share more about T.E.A.M. Mom and also learn more about the mom's current situation and how we can potentially help!
Primary Contact Phone Number*
Primary Contact Email*
example@example.com
Preferred method of communication*

EmailTextPhone
Select your Initial Session Follow Up Date (Virtual)*
I agree that the above information provided is accurate to the best of my knowledge. I also agree to allow T.E.A.M. Mom to follow up with me for an initial session.*

Yes
Please verify that you are human*
Should be Empty:

Applicant Information

Parent/Guardian Information

Let's Connect!