Keturah's Haven Pre- Intake Form

Qualifications For Our Program

Pregnant, homeless women ages 18-30

Currently drug and alcohol-free

Free from diagnosed severe mental illness

Without other children in her care

Must be willing to work part-time if resident has GED or high school diploma

Must be willing to participate in GED classes and volunteer

All fields are required to be filled.

Name : *

Date Of Birth :*

Email: *

Baby Due Date :*

Phone Number : *

How soon would you need shelter ? Where do you live now?*

Have you lived in a shelter before ? *

Keturahs Haven is a Christ centered program and organization. Are you ok with that?

YesNo

Our program home is managed by house parents. Do you have any issues being around a safe mother or father figure?

Do you have a history of substance abuse or mental illness*

Are you currently on any medications ? If so please list below:*

Do you have insurance or medicaid ?*

Social Security ( last 4 digits ) :*

Drivers License/ State ID # : *

Proof of pregnancy ( clinic or primary care doctor ) :*

Have you ever been tested for TB ? If so, when?*

Medicaid # *

Shelter with a child or without a child? (We only house pregnant women)*

What else would you like us to know*

How did you hear about us?*