Pre-assessment Screening Form
Email *
Please note: We are not currently equipped to accept women with other children in their care.
Contact Information
Full Name  *
Date of Birth *
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Phone Number  *
Email Address
Social Security Number *
Do you have other children in your care? *
Housing
Current or Most Recent Living Situation *
Education
Where did you attend high school? *
Highest grade completed? *
Did you graduate? *
Did you attend college? *
If Yes, Where? *
Have you received any specialized training? Please explain. *
Employment History
Number of jobs held in the past year? *
Reason no longer employed (if applicable)
Additional work skills you may have *
Work Attitude and Habits
How do you see yourself in the workplace? *
What kind of employee do you consider yourself? *
Are you seeking any job skills (i.e. writing resumes, job interview techniques, etc.)? *
Medical History- Last Exams
Name of Primary Care Doctor
Are you currently being seen by an OB? If so, what is the name of the doctor? *
What was the date of your last ultrasound? *
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Please list any current medications and dosage. *
What was the date of your last physical? *
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Findings *
Due Date *
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What was the date of your last dental visit?
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Findings
What was the date of your last vision check?
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Findings 
What actions do you feel are needed to improve your physical health? *
Mental Health History
Check each category that has (ever) been experienced. *
Required
Have you ever been hospitalized for mental health treatment? If so, when?  *
Legal History
Do you have a valid driver's license? *
If no, why not? *
If no driver's license, do you have a photo I.D.? *
Do you have car insurance? *
If yes, insurance information: *
Do you have an arrest record? *
If yes:
Charge: *
Date: *
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Conviction *
Sentence *
Charge:
Date:
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Conviction
Sentence
Charge:
Date:
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Conviction
Sentence *
Have you been to drug court? *
If Yes, Date and Sentence 
Probation/Parole Officer (if applicable)
Phone:
Upcoming Court Dates:
Substance Abuse
Do you drink alcohol? *
If yes, how often?
Do you use prescription drugs? *
Do you use street drugs? *
Do you smoke or vape? *
History of any substance use: *
Are you clean/sober? *
If so, how long?
Are you involved in a recovery program? *
Are you currently taking Methadone or Suboxone? *
Do you have any substances in your system now? *
Are you opposed to random drug and alcohol tests? *
Domestic Violence
Are you involved in a domestic violence situation? *
If yes, physical, emotional, verbal, or sexual?
Are you in fear for your safety? *
Who is your perpetrator? *
Family/Social Support
Are your parents involved? *
If you have siblings, are they involved?
Clear selection
Is the father of the baby involved? *
If yes, do you see a future relationship with him?
What are your interests/hobbies? *
Are you involved in any organizations (school, church, service)? *
Social Services History
What outside help are you currently receiving?  *
Please check the agencies you are working with or have worked with in the past: *
Required
The following services are provided for your benefit. Please check the top three (3) in order of priority: *
Required
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