Personal Information
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Age
*
Date of Birth
*
Ex. 05/17/2001
Birthplace
*
Ex. Dallas, Texas
Marital Status
*
Single
Married
Divorced
How did you learn about the Rooted program?
*
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Family Information
Your Father's Name
First Name
Last Name
Natural Father's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Father's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Your Mother's Name
First Name
Last Name
Natural Mother's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Mother's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are your parents...
Married and living together
Married not living together
Divorced
Never married
If one of your parents is deceased, please tell us there name below.
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Education and Employment
Last grade of school completed:
Did you receive a Diploma or GED?
No
Diploma
GED
What college did you attend or graduate from?
Ex. El Centro
Where is that college located?
Ex. Mesquite, Texas
Do you wish to attend college?
Yes
No
What would be your field of study?
Ex. Elementary Education
Please provide an employment history
Rows
Employer Name
Length of Employment
Reason for Leaving
1
2
3
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Community and Church
Have you ever belonged to a school organization, club, or extracurricular activity?
Have you ever done volunteer work? If so, what and where?
Have you ever attended church?
Yes
No
What Denomination or Particular Faith?
Yes
No
Are you part of a Denomination or Particular Faith?
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Medical (if applicable)
Who confirmed your pregnancy?
Do you have any other children?
Yes
No
If yes, please list ages of your children.
Would your children need to come with you to Selah Creek?
Yes
No
Have you had any previous miscarriages?
Yes
No
Have you had any previous abortions?
Yes
No
Do you have any high-risk pregnancy or medical problems?
What is your due date?
Ex. 05/17/2021
Do you have any medical problems? (ie. asthma, allergies, diabetes, etc.)
Do you have any contagious diseases?
Do you have medical coverage or assistance?
What is the name of the father of the baby?
First Name
Last Name
Father's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Income / Assistance
Do you have any source of income?
Do you have any cash assistance?
Medicaid?
Yes
No
Food Stamps?
Yes
No
WIC?
Yes
No
Parents or Relatives?
Yes
No
Baby’s Father?
Yes
No
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Substance Abuse
Do you have a history of using drugs or alcohol? Explain below.
Have you been or are you currently in treatment for drug or alcohol recovery?
Yes
No
How long was your treatment?
What type of of treatment?
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History
Have you ever been arrested?
Yes
No
If yes, explain below.
Are you currently on probation or parole?
Yes
No
Supervising Officer:
First Name
Last Name
Supervising Officer Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have a history of emotional or mental diagnosis?
Yes
No
If yes, explain the diagnosis below.
Are you currently in counseling or psychiatric treatment?
Yes
No
If yes, what provider?
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Miscellaneous
Do you have a valid driver’s license or permit?
Yes
No
Do you own a car?
Yes
No
Have you lived independently in the past?
Yes
No
What will be your relationship with your immediate family while being in the Rooted program?
Why do you want to come to participate in the Rooted Program?
What will be your relationship with your boyfriend / birth father while being in the Rooted program?
What other relationships will be important to you while being in the Rooted program?
Are there any changes you want to make to your life?
What are your main concerns right now?
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What do you eventually want your life to be like?
Is there anything else you would like us to know about you, your baby, or your family?
Should be Empty: