Initial Intake Form

Initial Intake Form

I understand that Mama's House Ministries is not an emergency shelter and that by filling out this form I am submitting to see if I am eligible to go through the Intake Process to become a resident of Mama's House Ministries.
About You
Your Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Are you a U.S. citizen?*

YesNo
Ethnicity*
If other, please describe:
Best Phone Number to Reach You*
Please enter a valid phone number.
Any Other Phone Number?
Please enter a valid phone number.
Your Email Address
example@example.com
How did you hear about Mama's House?*

Agency/OrganizationFriend or FamilyOnline or Social MediaHealthcare ProviderOther
If you selected "Agency/Organization," or "Other," please provide the name of the agency/organization or how else you heard about our organization
Pregnancy & Kids
Are you pregnant right now?*

YesNo
Has a doctor or healthcare provider confirmed your pregnancy?*

YesNo
If yes, where?
How far along are you?*
If you come for a second interview, would you be able to show proof of pregnancy?*

YesNo
Do you have other kids?*

YesNo
If yes, how many and what are their ages?
Are your other kids living with you?*

YesNo
If not, who's taking care of them?
Safety
Is there anyone or any situation making you feel unsafe right now?*

YesNo
Have you ever experienced emotional, physical, or sexual harm from someone?*

YesNo
Where have you been staying recently? This helps us understand your safety needs.
Our Program Values

Mama's House is a Christian-based program supporting pregnant women and moms with kids 3 and under. You don't have to be a Christian to join us, but we do ask that you're respectful of our faith-based environment.
We have some spiritual activities we expect residents to join in on, like:
- Daily devotional time
- Weekly Bible study
- Celebrate Recovery meetings
- Church services
Our program is based on Christian values like kindness and respect-- treating others the way you'd want to be treated.
Does that sound like something you'd be okay with?*

YesNo
About Our Probationary Period

If you join Mama's House, you'll have a probation period. It's designed to help you focus on healing by giving you space away from unhealthy people or habits. During this time, no cell phone use is allowed and there are limits on where you can go and who can visit.
How do you feel about that?*

Okay with itNot sureNot okay right now
Thank you for your openness & for reaching out to Mama's House Ministries.

Your answers will remain confidential. Your responses will be reviewed and you will be contacted if eligible for a second interview. Documentation may be required. If you have any immediate needs, dial 2-1-1 for a directory of local resources and 9-1-1 if you're in any danger.

"My help comes from the Lord, Who made heaven and earth."

-Psalm 121:2
Should be Empty:

Initial Intake Form

About You

Pregnancy & Kids

Safety

Our Program Values

About Our Probationary Period