Resident Application

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Phone NumberWhat is the best phone number to reach you?
Please enter a valid phone number.
4
Your EmailWhat is the best email where we can reach you?
example@example.com
5
What is your preferred contact method when contacting you about your application?* This field is required.
Phone
Email
No Preference
6
Your Current AddressPlease fill out to the best of your knowledge.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
How long have you lived at your current address?If you don't know exactly, please give your best estimate.
8
Who do you currently live with?Pleas provide names and their relationship to you (boyfriend, friend, grandmother, mom, etc.)
9
Would you consider your current living situation SAFE?* This field is required.Please choose one.
Yes
No
Unsure
10
If No or Unsure, please explain:What makes your current living situation unsafe?
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Ok
11
Would you consider your current living situation STABLE?* This field is required.Is it possible and safe for you to remain where you are for the next 6-9 months?
Yes
No
Unsure
12
If No or Unsure, please explain:Why is your current living situation unstable?
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Ok
13
Is anyone pressuring you to have an abortion?
Yes
No
14
How did you hear about The Haven?* This field is required.
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Ok
15
Why do you want to live at The Haven during your pregnancy and how do you think living at The Haven will benefit you?* This field is required.
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16
Name of an Emergency Contact* This field is required.
17
Your Emergency Contact's relationship to you:* This field is required.(For example- Mom, Aunt, Friend, etc.)
18
Emergency Contact's Phone Number* This field is required.
Please enter a valid phone number.
19
Do you currently have any children in your care or physical custody of any children?* This field is required.
YESNO
20
What is your Marital Status?* This field is required.
Single, never married
Married
Married but seperated
Divorced
Widowed
21
How has your pregnancy been confirmed?* This field is required.Check all that apply
Missed period
Home pregnancy test (dye test)
Home pregnancy test (Digital)
Urine pregnancy test at a Doctor's Office or Medical Facility
Blood test at a Doctor's Office or Medical Facility
22
If the test was performed at a Doctor's Office or Medical Facility, what is the name of the Doctor or the name of the Medical Practice that performed the pregnancy test?
23
Expected Due DateIf Known- When is your baby due? Leave BLANK if you do not know.
Date
Month
Day
Year
24
If Expected Due Date is UNKNOWN, when was the first day of your last period?If you do not know the exact date, please give your best guess.
Date
Month
Day
Year
25
If expected Due Date is UNKNOWN, do you have regular periods?Skip if not applicable
YESNO
26
Have you had any prenatal care during THIS pregnancy?* This field is required.
YESNO
27
If Yes, where did you last receive prenatal care?Name or Doctor or Medical Practice
28
Phone Number of Doctor or Medical Practice where you are receiving Prenatal Care:
Please enter a valid phone number.
29
Date of LAST prenatal appointment:
Date
Month
Day
Year
30
Date of NEXT prenatal appointment:If you have one scheduled. If no appointment is scheduled, please leave blank
Date
Month
Day
Year
31
Are you experiencing any pregnancy complications or has you baby been diagnosed with any medical problems?* This field is required.
YESNO
32
If Yes, please describe:
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33
How long has it been since your last routine OBGYN check-up?Please provide a date or your best guess (6 months, 2 years, etc.) if you do not know the exact date. If the answer is NEVER please leave blank.
34
Name and Location (city and state) of last OBGYN seen (if ever)Please provide the Name or the Doctor and/or the name of the Medical Practice and where they are located.
35
Have you ever been pregnant before this current pregnancy?* This field is required.Including pregnancies that ended in births, miscarriages or abortions.
YESNO
36
If Yes, Number of previous pregnancies:How many times have you been pregnant BEFORE this pregnancy Including live births, stillbirths, miscarriages, and abortions?
37
Previous Pregnancy Outcomes:Please select how many pregnancy outcomes in each category that apply
1
2
3
4 or more
Live Births (Full Term, 37 weeks or more)
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Row 0, Column 3
Live Births (Pre-term 32-37 weeks)
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Row 1, Column 3
Live Births (Pre-term 28-31 weeks)
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Live Births (Pre-term less than 28 weeks)
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Stillbirths/ 3rd trimester Miscarriages
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Miscarriages (2nd trimester)
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Row 5, Column 3
Miscarriages (1st trimester)
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Row 6, Column 3
Abortions
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Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Live Births (Full Term, 37 weeks or more)
Live Births (Pre-term 32-37 weeks)
Live Births (Pre-term 28-31 weeks)
Live Births (Pre-term less than 28 weeks)
Stillbirths/ 3rd trimester Miscarriages
Miscarriages (2nd trimester)
Miscarriages (1st trimester)
Abortions
1
Row 0, Column 0
2
Row 0, Column 1
3
Row 0, Column 2
4 or more
Row 0, Column 3
1
Row 1, Column 0
2
Row 1, Column 1
3
Row 1, Column 2
4 or more
Row 1, Column 3
1
Row 2, Column 0
2
Row 2, Column 1
3
Row 2, Column 2
4 or more
Row 2, Column 3
1
Row 3, Column 0
2
Row 3, Column 1
3
Row 3, Column 2
4 or more
Row 3, Column 3
1
Row 4, Column 0
2
Row 4, Column 1
3
Row 4, Column 2
4 or more
Row 4, Column 3
1
Row 5, Column 0
2
Row 5, Column 1
3
Row 5, Column 2
4 or more
Row 5, Column 3
1
Row 6, Column 0
2
Row 6, Column 1
3
Row 6, Column 2
4 or more
Row 6, Column 3
1
Row 7, Column 0
2
Row 7, Column 1
3
Row 7, Column 2
4 or more
Row 7, Column 3
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38
Did you have any medical complications during any of your previous pregnancies?
YESNO
39
Please describe the medical complications you have had during previous pregnancies:
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40
If Live Births, how many were delivered vaginally?Leave blank if not applicable.
41
If Live Births, how many were delivered by C-section?Leave blank if not applicable.
42
Have you ever chosen Adoption for any of your previous children?
YESNO
43
If you do not have custody of your child(ren) (and they were not placed for adoption at birth), who currently has custody of them and what were the circumstances that led to them being cared for by someone other than yourself?Leave blank if not applicable to you.
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44
What is the Father's name of your unborn baby?* This field is required.If unknown, type UNKNOWN
45
Was your baby conceived WITHOUT your consent?(rape or sexual assault)
YESNO
46
Have you filed a police report?
YESNO
47
What is your current relationship to your Baby's father?* This field is required.
Wife
Fiancé
Girlfriend (dating/in a committed relationship)
Just a Friend
Not in a relationship or no longer in a relationship
Other
48
Does the Baby's Father know that you are pregnant?* This field is required.
YESNO
49
If Yes, how does he feel about the pregnancy and the baby?
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50
Does the Father of the Baby know that you are applying to live at The Haven?
YESNO
51
If Yes, how does he feel about you wanting to live at The Haven?
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52
Is the Father of the Baby supporting you and the Baby financially?
YESNO
53
Has there been any Domestic Violence or Sexual Assault between you and your Baby's Father?
YESNO
54
If Yes, is there a current Order of Protection (restraining order) that you have against him or he has against you?
YESNO
55
To your knowledge, has he ever been involved in ANY domestic violence or sexually assaulted anyone other than you?
YESNO
56
If yes, please explain:
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57
To your knowledge, does he have a criminal record or has he ever been violent with anyone, even if he wasn't arrested for it?
YESNO
58
If Yes, please explain:
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59
To your knowledge, does your Baby's Father have a history of drug or alcohol use or dependence?
YESNO
60
If Yes, please explain:
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61
If you are not in a committed relationship with your Baby's Father, are you in a committed romantic relationship with anyone else?Skip if this does not apply to you.
YESNO
62
If Yes, do they know you are pregnant?
YESNO
63
If Yes, how do they feel about the pregnancy and you applying to live at The Haven?
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64
If your current partner is someone other than your Baby's Father, has there ever been any domestic violence or sexual assault between you or your current partner?
YESNO
65
If Yes, is there a current Order of Protection (restraining order) between you and your current partner?
YESNO
66
If your current partner is not your baby's Father, to your knowledge have they ever been involved in any criminal activity (even if they were not arrested or charged)?
YESNO
67
If Yes, please explain:
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If your current partner is not your Baby's Father, to your knowledge do they currently use or have a history of drug or alcohol use or dependence?
YESNO
69
If Yes, please explain:
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70
Are you currently trying to escape ANY kind of domestic violence situation?* This field is required.
YESNO
71
If Yes, please explain:
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72
Do you have a copy of your Birth Certificate?* This field is required.
YESNO
73
Do you have a copy of your Social Security Card?* This field is required.
YESNO
74
Do you have a valid Driver's License?* This field is required.
YESNO
75
Do you have a State Issued ID?
YESNO
76
Do you own a vehicle?* This field is required.
YESNO
77
If Yes, what year, make, and model is your vehicle?For example: 2015 Honda Accord
78
If you own a vehicle, please select one:
I have current Registration (tags) AND current Vehicle Insurance
I have current Registration (tags) but I do NOT have current Vehicle Insurance
I do NOT have current Registration (tags) but I DO have current Vehicle Insurance
I do NOT have current Registration (tags) AND I do NOT have current Vehicle Insurance
79
Do you currently have a Primary Care Doctor (other than an OBGYN)?* This field is required.
YESNO
80
If Yes, Name or Primary Care Doctor or Medical Practice:
81
Phone Number of Primary Care Doctor or Practice
Please enter a valid phone number.
82
Date of last Physical Exam:If you do not know the exact date, please give your best guess.
Date
Month
Day
Year
83
Date of your next scheduled Primary Care appointment (if applicable);Leave blank if no appointment is scheduled
Date
Month
Day
Year
84
Do you have any chronic illnesses or medical problems? (Not related to pregnancy)* This field is required.Example: Diabetes, Hypertension, Seizures, Genetic Conditions, Asthma, Heart Conditions, etc.
YESNO
85
If Yes, please list conditions and any pertinent information:
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86
Have you had any surgeries or hospitalizations in the past?* This field is required.
YESNO
87
If Yes, please provide details of each surgery and hospitalization including dates if known.
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88
Do you have any Communicable Diseases?* This field is required.Example: HIV/AIDS, Hepatitis, any sexually transmitted illnesses, etc.)
YESNO
89
If Yes, please provide details:
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90
Are you currently taking or are your prescribed any medications? (Including prescriptions and over-the-counter medications taken regularly)* This field is required.
YESNO
91
If Yes, please list each medication with the dosage, how often you take it, and what you take it for.Please include prescribed and over-the-counter medications
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Do you have any Allergies?* This field is required.Including Food, Medication, substances, Environmental, etc.
YESNO
93
If Yes, please list each allergy as well as your reaction to each:For example: Penicillin- hives, Peanuts- difficulty breathing
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94
Please fill out the Family Medical History Chart below:* This field is required.Do any of your close relatives have any of the following medical problems?
Parent
Sibling
Grandparent
Child
Other
None Known
Heart Disease
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Stroke
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Row 1, Column 5
Cancer
Row 2, Column 0
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Row 2, Column 5
Hypertension
Row 3, Column 0
Row 3, Column 1
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Row 3, Column 5
Diabetes
Row 4, Column 0
Row 4, Column 1
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Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Asthma
Row 5, Column 0
Row 5, Column 1
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Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Autoimmune Disorders
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
Psychiatric Illness
Row 7, Column 0
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Row 7, Column 3
Row 7, Column 4
Row 7, Column 5
High Cholesterol
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Row 8, Column 5
Heart Disease
Stroke
Cancer
Hypertension
Diabetes
Asthma
Autoimmune Disorders
Psychiatric Illness
High Cholesterol
Parent
Row 0, Column 0
Sibling
Row 0, Column 1
Grandparent
Row 0, Column 2
Child
Row 0, Column 3
Other
Row 0, Column 4
None Known
Row 0, Column 5
Parent
Row 1, Column 0
Sibling
Row 1, Column 1
Grandparent
Row 1, Column 2
Child
Row 1, Column 3
Other
Row 1, Column 4
None Known
Row 1, Column 5
Parent
Row 2, Column 0
Sibling
Row 2, Column 1
Grandparent
Row 2, Column 2
Child
Row 2, Column 3
Other
Row 2, Column 4
None Known
Row 2, Column 5
Parent
Row 3, Column 0
Sibling
Row 3, Column 1
Grandparent
Row 3, Column 2
Child
Row 3, Column 3
Other
Row 3, Column 4
None Known
Row 3, Column 5
Parent
Row 4, Column 0
Sibling
Row 4, Column 1
Grandparent
Row 4, Column 2
Child
Row 4, Column 3
Other
Row 4, Column 4
None Known
Row 4, Column 5
Parent
Row 5, Column 0
Sibling
Row 5, Column 1
Grandparent
Row 5, Column 2
Child
Row 5, Column 3
Other
Row 5, Column 4
None Known
Row 5, Column 5
Parent
Row 6, Column 0
Sibling
Row 6, Column 1
Grandparent
Row 6, Column 2
Child
Row 6, Column 3
Other
Row 6, Column 4
None Known
Row 6, Column 5
Parent
Row 7, Column 0
Sibling
Row 7, Column 1
Grandparent
Row 7, Column 2
Child
Row 7, Column 3
Other
Row 7, Column 4
None Known
Row 7, Column 5
Parent
Row 8, Column 0
Sibling
Row 8, Column 1
Grandparent
Row 8, Column 2
Child
Row 8, Column 3
Other
Row 8, Column 4
None Known
Row 8, Column 5
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95
Are you currently or regularly experiencing any of the following medical symptoms?Check all that apply
Headaches
Dizziness
Shortness of Breath
Chest Pain
Abdominal Pain
Joint Pain
Muscle Weakness
fatigue
Insomnia
96
Do you have any other health problems or concerns not yet listed?* This field is required.
YESNO
97
If Yes, please describe:
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98
Do you currently use any smoking or tobacco products?* This field is required.Including smoking cigarettes or cigars, vaping, electronic cigarettes, and any chewing/dipping products)
YESNO
99
If Yes, what type of smoking or tobacco products do you use, how often do you use them and for how long have you been using them?
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100
Have you ever tried to quit?
YESNO
101
If you have tried to quit, what methods did you try and how long ago did you try them?For example- cold turkey, patches, gum, etc.)
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Are you willing to quit to improve your health and for the health of your baby?
YESNO
103
If you are not currently smoking or using tobacco products, have you EVER smoked or used tobacco products in the past?Regular use, such as at least once a day for a period of one month or longer.
YESNO
104
If Yes, what type of tobacco products did you previously use?
105
How long ago did you quit?
106
Have you drank any alcohol since your pregnancy began?* This field is required.
YESNO
107
If Yes, please describe how often and how much alcohol you have been drinking since you found out you were pregnant:
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108
Do you currently use any drugs illegally?* This field is required.This includes any illegal drugs, any prescription drugs that are not prescribed to you or any prescription drugs in a way other than how they are prescribed.
YESNO
109
If Yes, please list the types of illegal drugs you have used since becoming pregnant, how often you have been using, and when was the last time you used.
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110
If Yes, do you consider yourself addicted to or dependent any drugs or medication?
YESNO
111
If Yes, which ones are you currently addicted to or dependent on?
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112
Are you willing to take a drug screen before entering The Haven?* This field is required.
YESNO
113
Are you currently or have you ever attended any type of Drug or Alcohol Rehab program?
YESNO
114
If Yes, please list the name(s) of the program(s), location(s), how often you attended or how often you currently attend and date of last attendance. If you are no longer in the program please explain why.
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115
Do you have any dietary needs or restrictions?* This field is required.
YESNO
116
If Yes, please describe:
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117
How often do you exercise?* This field is required.
Daily
Several times a week
Once a week
Rarely
Never
118
To your knowledge, are you up to date on your routine vaccinations?* This field is required.
Yes
No
Unknown
119
How long ago was your last Flu vaccine?
120
How would you describe your current mental health status?* This field is required.
1
2
3
4
5
Poor
Excellent
121
Are you currently experiencing any of the following? (Check all that apply)
Depression
Anxiety
Stress
Mood swings
Other Mental Heath Distress
122
Have you ever been Diagnosed with any of the following? (check all that apply)
Depression
Anxiety
Bi polar 1
Bi polar 2
Borderline Personality Disorder (BPD)
Oppositional Defiance Disorder (ODD)
Eating Disorder
Schizophrenia
Post Traumatic Stress Disorder (PTSD)
Dissociative Identity Disorder
Obsessive Compulsive Disorder (OCD)
Panic Disorder
Reactive Attachment Disorder (RAD)
Premenstrual Dysphoric Disorder (PMDD)
Other Mental Health Condition
Other
123
If "Other Mental Health Disorder", Please specify:Leave blank if not applicable
124
Have you ever been hospitalized for a mental health condition?
YESNO
125
If Yes, how many hospitalizations?
126
How long ago was your last hospitalization for Mental Health?
127
What was your length of stay for your last hospitalization for Mental Health?
128
Are you currently under the care of any Mental Health Professional?* This field is required.Including psychologists, psychiatrists, counselors, social workers, etc..
YESNO
129
Name and Title of Mental Health Professional who you see or the Practice name:Example: Dr. John Smith- Psychiatrist or Counselor at Long Street Counseling Center
130
Phone Number of your Mental Health Professional
Please enter a valid phone number.
131
Date of last Mental Health appointment
Date
Month
Day
Year
132
Date of next scheduled Mental Health appointment If applicable
Date
Month
Day
Year
133
Have you EVER been under the care of a Mental Health Professional in the past?
YESNO
134
Name or Practice name and type of last Mental health Professional:Example: Dr. John Smith- Psychiatrist or Counselor at Long Street Counseling Center
135
Phone Number of last Mental Health ProfessionalIf known
Please enter a valid phone number.
136
How long ago was your last visit to a Mental Health Professional?
137
Why did you discontinue care with your former Mental Health Professional?
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Have you ever been on any medications for any mental Health Disorders that you are no longer taking?
YESNO
139
If Yes, please list all previous medications taken for mental health including the name of medication, the last time you took the medication and the reason you discontinued use:
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140
Were you ever in Foster Care?* This field is required.
YESNO
141
Please describe your history in foster care including ages you were in foster care and number of placements.* This field is required.
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142
Did you leave Foster Care because you aged out?* This field is required.
YESNO
143
Have you ever lived in a group home setting?* This field is required.
YESNO
144
Please describe your history with group homes.
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145
Do you have Medical Insurance?* This field is required.Private or Medicaid
YESNO
146
If Yes, Name of Medical Insurance Provider:
147
Medical Insurance Policy #:
148
Medical Insurance Group #
149
Have you applied for Medicaid since you found out you were pregnant?
YESNO
150
Are you currently enrolled in W.I.C.?* This field is required.Women, Infant, and Children Special Supplemental Nutrition Program
YESNO
151
Do you currently receive SNAP benefits?* This field is required."food stamps"
YESNO
152
Do you currently receive assistance through TANF?* This field is required.Temporary Assistance for Needy Families
YESNO
153
Do you currently have a Dentist?* This field is required.
YESNO
154
If Yes, Name of Dentist or Dental Practice
155
Your Dentist's Phone Number:
Please enter a valid phone number.
156
Date of last Dental Exam or Cleaning:
Date
Month
Day
Year
157
Date of next scheduled Dental Exam, Treatment or Cleaning:Leave blank if not applicable
Date
Month
Day
Year
158
If No, approximately how long has it been since you last had an appointment with a Dentist?
159
Name or last Dentist or Dental Practice seen: If known
160
Do you have any current dental problems or ongoing dental needs?
YESNO
161
If Yes, please describe:What are your current dental problems or needs?
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Do you currently have Dental Insurance?* This field is required.
YESNO
163
If Yes, name of Dental Insurance Plan:
164
Dental Insurance Policy #:
165
Do you currently have an Eye Doctor?* This field is required.Either an Optometrist or Ophthalmologist
YESNO
166
If Yes, what is the name of your Eye Doctor or the Practice where you receive vision care?
167
Eye Doctor's Phone Number:
Please enter a valid phone number.
168
Date of last Eye Exam:Please use your best guess if you do not know the exact date
Date
Month
Day
Year
169
Date of next scheduled Eye Exam:if applicable
Date
Month
Day
Year
170
If No, approximately how long has it been since your last eye exam?
171
Where was your last Eye Exam?Name of Doctor or Vision Practice, if known.
172
Do you use or need any of the following:* This field is required.
Glasses (Full time)
Glasses (Part time, for example- while driving or while reading)
Soft Contact Lenses
Hard Contact lenses
I do not need Glasses or Contact Lenses
173
If you wear contact lenses, do you currently have a pair of back-up glasses?
YESNO
174
Approximately how long will it be before you need to order more contacts ?Based on suggested wear time, not overwearing
175
Are your Glasses your most recent prescription?
YESNO
176
How long have you had your Glasses?
177
Do you have any eye problems or vision problems or any ongoing eye care needs?*Other than needing glasses/contacts
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Do you have Vision Insurance?* This field is required.
YESNO
179
If Yes, name of Vision Insurance:
180
Vision Insurance Policy #:
181
Have you ever been a victim of any abuse or neglect?* This field is required.Including physical, emotional, sexual or other
YESNO
182
If Yes, approximately how old were you when the abuse/neglect began?
183
What was your abusers relationship to you?Example: neighbor, family friend, classmate, family member, boyfriend, etc.
184
Did you ever receive counseling for the abuse/neglect?
YESNO
185
Have you ever committed a crime other than a minor traffic offense?* This field is required.
YESNO
186
If Yes, please explain including any charges, arrests, and sentences:
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Are you currently on Probation or Parole?
YESNO
188
If Yes, please explain including the Jurisdiction, Name, and Phone # of your Probation or Parole Officer and date your probation or parole will be completed:
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189
Do you have any pending criminal charges against you or warrants for your arrest?* This field is required.
YESNO
190
If Yes, please explain including any scheduled court dates and locations:
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Are you willing to submit to a Criminal Background Check as part of the application process?* This field is required.* A Criminal history is NOT a sole reason for an application to be denied.
YESNO
192
What is your highest level of Education?* This field is required.
Some Middle School
Some High School
GED
High School Diploma
Some Technical School
Technical School Graduate
Some College
Associates Degree
Bachelors Degree
Other
Other
193
Please provide additional details about your educational history including current or last school attended, highest grade completed, year of graduations or GED, and types of diplomas or degrees earned:* This field is required.
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Have you ever been diagnosed with a Learning Disability?* This field is required.
YESNO
195
If Yes, please describe including diagnosis and any history of IEPs or 504 plans:
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What, if any, are your current Educational Goals?* This field is required.
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197
Do you currently have a Job?* This field is required.
YESNO
198
If Yes, what is the name of the company you work for?
199
Work Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
200
Your Job Title:
201
How long have you worked at your current job?
202
Average weekly income:
203
What does your weekly job schedule typically look like?
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204
If No, have you ever had a job before?
YESNO
205
If Yes, please describe your employment history including where you were last employed, last job title held, reason for leaving and how long you have been unemployed:
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206
What are your Employment Goals?* This field is required.
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207
Do you receive income from any source other than employment?* This field is required.For example: social security, disability, government assistance, alimony, etc..
YESNO
208
If Yes, please describe including how much you receive monthly in assistance and from what source:
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209
Is there currently anyone helping to support you financially?For example: giving you money regularly, helping you pay bills, paying for your food, etc.
YESNO
210
If Yes, please describe who is helping support you financially and how they are providing support:
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211
Do you have any Debt?* This field is required.Including car payments, student loans, payday loans, credit card balances, outstanding medical bills, court judgements, past due utility bills or rent, etc. This does NOT include routine monthly bills, such a cell phone or streaming services unless you are behind on payments.
YESNO
212
If Yes, please describe your debts including what type of debts you have, the estimated total amount of each debt, and if the debts are currently in collections:
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213
Do you have any recurring regular Expenses?* This field is required.For example- scheduled debt payments in a payment plan, car payment, car insurance, medical insurance, cell phone, streaming services, etc.
YESNO
214
If Yes, please list your regular expenses and monthly payments for each expense:
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215
Do you have a Bank Account?* This field is required.
YESNO
216
If Yes, please list the types of accounts you have which bank they are located:checking, savings, retirement, etc.
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217
Do you have a plan to financially support yourself and your baby, if you choose to parent, after you leave The Haven?* This field is required.
Yes
Not yet
218
If Yes, please explain your plan:
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Are you or have you ever been affiliated with any Religion or Church?* This field is required.
YESNO
220
If Yes, please describe your past and present involvement with religion or church:
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221
Briefly describe any Hobbies and Interests you have:* This field is required.
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Do you currently have a plan for where you will live after you leave The Haven?* This field is required.
Yes
Not yet
223
If Yes, please describe your plan:
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If you are able, and to help speed up the application process, please upload any of the following that you have available: Birth Certificate, Social Security Card, Driver's License, Sate Issued ID, Medical Insurance Card, Dental Insurance Card, Vision Insurance Card, Vehicle Insurance Card, Immunization Record, Last Report Card or Transcript, Proof of Pregnancy from a Medical PracticeIf you don't have a scanner, you can take a picture and upload the picture for now and we will scan the originals for you at a later date.
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SignatureBy signing below, I acknowledge that the information provided is accurate to the best of my knowledge and I consent to its use for the purpose of applying for residency at The Haven at Hebron.
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