Keturah's Haven Pre- Intake Form

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 participate in GED classes and volunteer

Must be 12 weeks to 6 months pregnant.
All fields are required to be filled.
Name : *
Date Of Birth :*
Email: *
Phone Number : *
Is it safe to contact you at this number?*

YesNo
Baby Due Date :*
What is your birth gender?*

MaleFemale
Most Recent Address:*
What County Do You Reside In Currently:*
Social Security ( last 4 digits ) :*
Do you have insurance or medicaid ?*
Medicaid # *
Drivers License/ State ID # : *
What best describes your current situation? Check all that apply.*

I just need help.I am experiencing domestic violence.I have been involved in labor trafficking,I have been sexually assaulted or raped.I am involved in sex trafficking.I am experiencing homelessness.
Do you have the desire to receive counseling?*

YesNo
How soon would you need shelter ? Where do you live now?*
Have you lived in a shelter before ? *
Have you served in the military?*

YesNo
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 curently taking any mental health medications? If so, list them.*
Do you need help getting medications that you should be on?*
Are you currently on any medications ? If so please list below:*
Proof of pregnancy ( clinic or primary care doctor ) :*
Is this your first child?*
Have you ever been tested for TB ? If so, when?*
Shelter with a child or without a child? (We only house pregnant women)*
Do you Use? (Check all that apply?)*

VapeCigarettesAlcoholMarijuanaMisuse prescriptionsAny other street DrugsNone of these
Do you have a drug of choice? If so, list it.*
Have you ever been treated for substance abuse?*

YesNo
What else would you like us to know*
Have you ever been convicted of a crime?*

YesNo
If you have been convicted of a crime, please list all dates and charges.
How did you hear about us?*
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