Name of Applicant
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you already had a one-to-one meeting with the Program Director: Mrs. Gwen
Please Select
Yes
No
If NO, you will be contacted by the WE LEAP Mommy Mentoring Academy program staff to schedule a virtual /Phone interview within 24-48 hours of our office receiving your application. *****If YES after your application has been received and reviewed you will be contacted regarding next steps based on eligibilty has been met to participate.
Select your age group
Please Select
13 - 17 years of age
18-24 years of age
What race are you?
Please Select
African American
Hispanic
Caucasian
Other
This question is important because there is significant differences in birth outcomes based on race and /or ethnicty.
What are your primary languages spoken in your home?
Please Select
English
Spanish
Creole
Bilingual - English / Spanish
Bilingual- English/Creole
How Often Have You Seen A Doctor For Prenatal Care?
Please Select
I have had 1 vist with a pregnancy doctor
I have had 2 or more visits since being pregnant
I have not been to a doctor for any pregnancy care.
Are you currently Enrolled in School
Please Select
Yes
No
If yes be prepared to answer this question during your interview?
Did you graduate?
Please Select
Yes - Highschool Diploma/GED
No - But- I would like help to get my Diploma/GED
No- Not interested in school right now.
Are you employed?
Please Select
Yes - Full-TIme
Yes- Part-Time
No- But Seeking Employment
No
Do you have your own laptop/ computer?
Please Select
Yes
No
Highest Education Achieved
Please Select
5th
6th
7th
8th
9th
10th
11th
12th
GED
Certification
AA/AS Degree
BA/BS Degree
Graduate Degree
Do you have your own vehicle?
Please Select
Yes
No
Will you have dependable transportation to get to appointments/ Mommy Mentor Academy Groups?
Please Select
Yes
No
*MENTORS CAN NOT TRANSPORT MENTEES* If transportation is needed, we can try to assist you with getting to appointments and to Mommy Mentoring Academy.
Civil Status
Single
Married
Divorced
Widowed
Is this your first pregnancy?
Please Select
Yes
No - I have another child
No -I was pregnant before- I miscarried/ lost the baby
How many children do you have now?
Please Select
Pregnant now- first child
Pregnant now plus 1 other child
Pregnant now plus 2 or more children
Right now, do you feel you have enough knowledge and support to become a mother for the first time?
Please Select
Yes - I got this, I know what I am doing, I have a strong support system.
No- I need and want to learn, I need some extra help on this journey.
What is your current living arrangment?
Please Select
I live in my own housing
I live with a parent or guardian
I live with other family
I live with friends
Other
Please be prepared to discuss this during your interview.
How many children live in your home under 5 years of age?
Please Select
None
1
2 or more
Are any children in the home with medical or special needs?
Please Select
Yes
No
Do you have trouble paying your bills?
Please Select
Yes
No
Not Applicable
Think back to just before you got pregnant and make a selection.
Please Select
I wanted to be pregnant now
I wanted to get pregnant later
I did not want to be pregnant
In the last year has anyone tried to hurt you or threatened to hurt you?
Please Select
Yes
No
During your interview be prepared to discuss this question.
Please select the best answer to describe your relationship with the father of your child.
Please Select
Yes, It is good, we get along and he is aware of the baby
Yes, it is okay, we get along but he is NOT aware of the baby I am carrying
No, we are not getting along and but he is aware of the baby I am carrying
No, we are not getting along and he is NOT aware of the baby I am carrying.
NO, I am not sure who the father is.
In the last month, have you felt alone when facing problems?
Please Select
Yes
No
Are you willing to attend a Mandatory 4-hour Orientation if selected for the program?
Please Select
Yes
No
The Orientation will be held on a Saturday- TBD- at Indian River State College In Fort Pierce.
In the last month have you felt down, depressed, or hopeless?
Please Select
Yes
No
Have you ever received mental health services or counseling?
Please Select
Yes
No
Do you REALLY want to have a mentor to support you through your journey of becoming a first-time mother?
Please Select
Yes - I REALLY want to do this!
No - I am not sure.
***Please Read: Can you commit to working with a mentor for 2-4 hours per week by: (1) being available to attend a 2 hour support group mentoring meeting one night a week with your mentor from 6pm - 8pm, for the duration of your pregnancy? (2) Being available to connect with your mentor for at least 2 documented hours per week outside of group time?*** We need dependable, coachable people for this assignment if you have any doubt that you can't be consistent, please reconsider applying for this opportunity and let other ladies that would really like to be here have this spot.
In the last month, how many alcoholic drinks did you have per week?
Please Select
0
1 or more
I dont drink alcoholic drinks
There will be no drinking allowed during your pregnancy for this program. ( We want healthy mommy's and healthy babies)
In the last month, how much many cigarettes or marijuanna did you smoke, or Vape Pen usage do you use per week?
Please Select
0
1 time or more
I dont smoke cigarrettes or Vape
There will be no smoking/Vaping allowed during your pregnancy for this program. (We want healthy mommy's and healthy babies)
This Mommy Mentoring Academy is Pilot Launch and mentors and mentees will be helping us to collect data to improve the program throughout the academy's first year. This is a group setting mommy mentoring academy. There will be other pregnant mothers on this journey with you as a team. The WE LEAP Mommy Mentor Academy is the first program of its kind in St. Lucie County. Tell us what you want from this program and, why you want to have a mentor and why you believe that mentoring support for a first-time pregnant teen or young adult is important.
Here is your time to shine, and share!
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