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Initial Intake
Thank you for inquiring to apply to Carried to Full Term. This will be the first part of your application. Please answer the questions below to help us determine if Carried to Full Term is a good organization for you. Completion of this form is not an automatic admittance into our home program. We recognize that our established program might not be appropriate for everyone. All applicants are evaluated on a case-by-case basis. CTFT staff will work collaboratively with other agencies in the community to assist pregnant women, such as yourself, to find the programs that best fit their individual needs.
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Email *
Today's Date *
Name:  *
Date of Birth *
Phone Number *
Email Address *
Preferred Contact
Have you taken a pregnancy test?
When is your due date? How many weeks are you?
Is this a high risk pregnancy?
Where are you calling from?
What is your current address?
Are you a U.S Citizen?
Do you have a SSN?
Marital status
Do you have any other children?
If, yes how many? Ages?
Are your children living with you?
If no, whom do your children live with
Do you have custody of your children?
If you do not have custody, are you in court or do you plan on going to court for custody?
Who has custody of the children?
Do you have children with special needs?
Are you currently taking any medications?
If yes, list Medications
Are you taking prenatal Vitamins
Have you been fully vaccinated for COVID-19?
Have you been diagnosed BY A DOCTOR with any of the following?
In the last six months have you taken illegal drugs or other substances?
If yes, Explain
Have you used marijuana in the past?
Have you used Any other drug in the past?
If yes, what and when
Do you smoke?
Do you Vape?
Are you currently employed?
Provide last 2 employers NAME AND PHONE
We require a background check of all potential residents. Do you understand that we will be taking this information and running a background check on you and do you give permission for this background check?
What is your social security number?
If NO or won’t provide SSN, do you understand that without a background check we cannot proceed to process your application fully?
Do you have a driver's license?  We will need this information as well for the background check.
State issued & Driver’s License #
How did you hear about Carried To Full Term?
Completion statement
We will take three (3) working days to get back in touch with you. At that time, we will let you know that we are able to proceed, and may ask you additional qualifying questions.
Questions & explanations
Signature: The individual verbalized their understanding of all above statements and agrees to move forward.
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