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  • CARES Program

    CARES Program

    Enrollment Form

  • If the entry is NEW the following will be displayed.

  • Welcome to the Mothers Helping Mothers CARES program!

    To provide you with resources and referrals in a safe, organized, and beneficial way Mothers Helping Mothers has partnered with Unite Us - a local agency that created an online platform that connects community partners & agencies with clients.

    A CARES team member from Mothers Helping Mothers will review your enrollment form and contact you by phone or text to schedule a time to conduct an interview.  

     

     

     

  • If the STATUS of the entry is Pending Fin Lit the following will be displayed and the user will be taken to the FINANCIAL LITERACY COMPLETION page.

  • FINANCIAL LITERACY PROGRAM

     

    To upload the certificates from the Financial Literacy course, click the NEXT button.

  • If the STATUS of the entry is P/S NEEDED the following will be displayed and the user will be taken to the POST SURVEY page.

  •  

    The final component of our CARES program is a

    follow up survey.

      Please help us by anwering the 8 questions below. 

    It should only take 2 minutes.

     

     

     

     

  • If the STATUS of the entry is P/S NEEDED but the user has already completed the survey - the following will be displayed and the user will be exited from the form.

  • You already completed the Post Survey on {postSurveyComp}.

     

    Thank you!

    Please exit the form.

     

     

     

    • PART A - Client Information 
  • Format: (000) 000-0000.
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  • Do not delete the fields below - the information is passed to this form by the HELP REQUEST form and will be used in TABLE view.

    • PART B - CLIENT SURVEY 
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    • S-1. In the past 3 months, have you or any familly members you live with been unable to get any of the following when it was need?

  • S-3 An EMERGENCY FUND provides security and the ability to cover loss of income for three months.  It should have enough to cover your expenses - rent, utilities and other monthly payments

    Use the following scale to rate your emergency fund:

    1 - NEEDS WORK - I do not have any savings.

    2 - WORKING ON IT - I have less than 1 month of expenses saved.

    3 - PRETTY GOOD - I have 1 month of expenses in my savings

    4 - GREAT! - I have 3 months of expenses in my savings.

  • Stress is when someone feels tense, nervous, anxious, or can't sleep at night because their mind is troubled.

     

    Think about the past month and answer the next 4 questions.

  • In the last month, how often has your stress level interfered with your ability to have positive interactions with your child(ren) such as quality time spent together, playing together, reading together, or just being present.

  • Authorization to Share Information with Partner Agencies

    I, the undersigned, hereby authorize Mothers Helping Mothers (MHM) to share relevant personal information and records about myself and/or my family with partner agencies, organizations, and service providers in an effort to coordinate and enhance the support and resources offered to me.

    I understand that this information will be shared solely for the purpose of helping me access additional services and resources that may benefit my well-being, including but not limited to housing, financial aid, healthcare, food assistance, childcare, and educational opportunities.

    I acknowledge that:

    Any information shared will remain confidential and only disclosed to agencies directly involved in providing services that support my needs.
    This consent is voluntary, and I may revoke it in writing at any time.
    Revocation will not affect information already shared prior to my written notice.


    MHM will not disclose my information to any entity not involved in my care or services without my explicit consent.

  • Clear
    • PART C - MHM Interview 

    • Fields are used by office staff - DO NOT DELETE

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    • PART D - Post Survey 

    • P-1 In the past 3 months, have you or any familly members you live with been unable to get any of the following when it was needed?

  • An EMERGENCY FUND provides security and the ability to cover loss of income for three months.  It should have enough to cover your expenses - rent, utilities and other monthly payments

    Use the following scale to rate your emergency fund:

    1 - NEEDS WORK - I do not have any savings.

    2 - WORKING ON IT - I have less than 1 month of expenses saved.

    3 - PRETTY GOOD - I have 1 month of expenses in my savings

    4 - GREAT! - I have 3 months of expenses in my savings.

  • Stress is when someone feels tense, nervous, anxious, or can't sleep at night because their mind is troubled.

     

    Think about the past month and answer the next 4 questions.

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  • In the last month, how often has your stress level interfered with your ability to have positive interactions with your child(ren) such as quality time spent together, playing together, reading together, or just being present.

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    • PART E - FINANCIAL LITERACY COMPONENT 
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    • If you have completed the BUDGET WORKSHEET please upload it below.

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  • Please click the SUBMIT button to submit your form.

     

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