HER FUTURE MATTERS Mentorship Program Participant Enrollment & Intake Form

Thank you for your interest in the Her Future Matters Mentorship & Incentives Program offered by Blessings Working Together, Inc.

This program is designed to support pregnant and parenting young women (ages 13–25) by connecting them with caring mentors, life skills education, parenting support, resources, goal planning, and community services that help build a stronger future for both mother and child.

During the program, participants may receive support with:

Housing and community resources
Education and employment goals
Parenting education
Financial literacy
Life skills and personal development
One-on-one mentoring
Referrals to community partners
Incentives for active participation

Program Commitment: Participants are asked to actively participate in the program for approximately 12 months by communicating with their mentor, attending scheduled meetings or workshops when possible, and working toward their personal goals.

What to Expect: This form should take about 5–10 minutes to complete. Your information will remain confidential and will only be used to determine eligibility and connect you with the services that best meet your needs. Completing this form does not guarantee enrollment, but it is the first step in joining the program.

We look forward to supporting you as you build a brighter future for yourself and your child.

Full Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

City

Are you currently:

What is your current living situation?

If other, please describe your current living situation

Do you currently have an open DFCS case?

What are your top three needs right now?

If other, please describe your top need(s)

Why are you interested in joining this program?

Are you willing to actively participate for at least 12 months?

Acknowledgment: If you are under age 18, a parent or guardian may be contacted to complete enrollment paperwork

How did you hear about us?

If other, please specify

I understand that submitting this form does not guarantee acceptance into the Her Future Matters Mentorship Program.

I understand that if selected, Blessings Working Together may contact me to discuss eligibility and next steps.

I understand that participants under age 18 may be required to obtain parent or guardian permission before enrollment.

Legal Full Name

Date

HER FUTURE MATTERS Mentorship Program Participant Enrollment & Intake Form

Participant Information

Current Status and Housing

Case and Needs Assessment

Program Participation and Acknowledgment

Referral Source

Acknowledgment