Application

Name

First NameLast Name

Do you go by a nickname or preferred name?

Date

Email

example@example.com

Phone Number

Please enter a valid phone number.

Your Date of Birth

Date

Name of referring agency:

Do you have a family member, friend or support person you'd like us to talk to in addition to you? Please list their name, number and relationship to you

Have you had a pregnancy test? What is your due date?

Do you have other children? If so, how old are they?

Who is presently caring for your other children?

Are you under obstetric care for this pregnancy? If so, where?

What insurance coverage do you have?

Are you a former foster youth? If so, are you enrolled in AB-12 aid? What county are you enrolled with?

Are you presently using illicit drugs? (Illicit drugs can include any "street" drug, including prescriptions, if you are either taking medications not prescribed to you, or taking them in a way that does not follow the instructed use)

Are you presently using alcohol or any product with THC, including legal marijuana products?

If yes to any of the questions above regarding drug and alcohol use, what substance(s) are you using, and how often?

If no to the questions about current use, have you used any of these substances in the past, and how long has it been since your last use?

Residents with a history of drug or alcohol abuse will be required to attend sobriety assistance programs in our area. Is this something you feel you can do?

Do you smoke, or use other nicotine products?

Have you ever been treated for mental health needs? If so, what was your diagnosis?

Are you currently under care for mental health needs? Where?

Residents with a history of mental health treatment will be required to make contact with appropriate care while in the program, and follow the treatment plan established. Are you willing to do this?

Besides obstetric care for your pregnancy, are there other immediate healthcare or wellness needs you would like to have addressed?

Are you current with the following vaccinations? (Proof of Covid 19 vaccination is required for residency.)

Covid 19 vaccinationCovid 19 boostersthis year's flu shotTdap

Have you ever been convicted of a crime?

Are you a survivor of a crime? (This might include robbery, assault, abuse, domestic violence, trafficking, exploitation, hate crimes, or any other illegal events you have experienced)

Are you currently involved in a pending court action or case? (This could be probation, parole, ongoing court appearances, wearing a monitor, etc)

Are you currently experiencing homelessness?

In the last 3 years, how many episodes of homelessness have you experienced? (An episode of homelessness is a separate, distinct stay on the street (or in a vehicle) and/or in an emergency shelter)

0123 or more

Please list any other housing programs or shelters you have received services from:

Are you in a relationship with the father of this pregnancy?

Have you ever experienced the following types of domestic violence?

physical abuseverbal abuseemotional abusemore than one type of abuse applies to my relationships

Does your current or most recent relationship involve domestic violence?

Have you ever been involved in a CPS case?

Have you completed high school? If not, how many credits do you need to finish?

Do you have references we can talk to? Please list their name, phone number and relationship to you. Please list as many as you think will benefit you.(Commonly listed references include social workers, shelter staff, teachers, foster system support, probation officers, counselors, employers, CPS workers, etc)

We are a semi-private facility. Residents have their own bedroom, and the rest of the Home is shared communal space. Each resident is responsible for helping to clean the house, cook at least one community meal per month, and participate in the community of the home. Is this something you are comfortable with?

On a scale of 1-10, with 10 being the best, how would you rate your ability to live with other adults you are not related to?

On a scale of 1-10, with 10 being the best, how would you rate your ability to follow rules?

We are located in Placerville, in El Dorado County. This is a rural/suburban setting. Do you think you have the ability to be satisfied living in a slow-paced area?

We run a program designed to help you develop a stable self-sufficient future. You will be working on a plan that is tailored to your needs, and you will be required to document your work towards self-sufficiency. What goals do you have for your future?

1. We are drug and alcohol free. You will be drug tested upon entry into the program, and randomly afterwards. An initial positive test is not a reason for denying program entry.

2. All residents must attend meetings and classes identified with the help of the Home Director, to promote their growth towards independence. These may include parenting and pregnancy related classes, recovery aid, counseling, and personal development classes or appointments, as identified based on your history.

3. All residents must have Medi-Cal or private insurance. Medi-Cal coverage must be transferred to El Dorado County if it is based elsewhere.

4. All residents must be vaccinated for Covid 19. Flu and Tdap vaccinations are also highly encouraged.

5. All residents must be seen regularly by an obstetrician. Mother Teresa Maternity Home can only provide transportation to Marshall Medical Center's obstetric clinic and birth center, located locally. Residents choosing a different medical team must provide their own transportation to appointments. All residents, regardless of the location of their care, will be required to tour the Marshall Birth Center in order to be familiar with the local option in case their first choice is unavailable.

6. We require proof of income, which may include current bank statements, Cash Aid statements, or pay stubs. A program fee is determined based on your income, not to exceed $200 per month.

7. Each resident is required to work toward their program goals 3 or more days per week. Examples of these goals are education, employment and housing search.

8. Residents must apply for WIC and Cal Fresh in El Dorado County, and maintain those services while here.

9. All residents must observe the House Rules, including curfew. Residents not observing the rules face immediate dismissal from the program.

I have read the baseline requirements for residency, and agree to them

Clear

Do you have any questions about Mother Teresa Maternity Home? We will try to answer these questions when we contact you.

We are glad you are taking this step in finding a safe, supportive place for you and your baby. Now that you have completed this questionnaire, an MTMH staff member will contact you within 72 hours to discuss options. If you have not received an email or phone call in that time, please call (530)295-8006.

Please verify that you are human*

MTMH Information Questionnaire

The following questions are personal. They are designed to help us determine how we can best help you. Please be honest with your answers

The following questions are about residential life at MTMH. Please answer honestly

Baseline Requirements for Consideration for Admission: