A Mother's Hope: Resident Application
If you have any questions concerning this form, please contact shay@amhfw.org.
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What is your first name? *
What is your last name? *
What is your date of birth? *
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What is your phone number? *
What is your email address? *
Are you pregnant? *
What is your approximate due date? *
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Are you currently homeless or at risk for homelessness? *
Reason for homelessness (check all that apply) *
Required
If you marked “other” above, please explain.
Can you pass a drug test? *
Are you willing to follow the rules and structure of the home? *
The program at A Mother's Hope includes an individual counseling requirement.  Are you willing to participate in counseling?
Clear selection
The program at A Mother's Hope includes productivity requirements (40 hours per week - classes, employment, medical needs, etc.). Are you willing to participate in the productivity requirements? *
Are you committed to living drug and alcohol free? *
If you smoke, are you willing to try to quit?
Clear selection
Do you have custody of other children? *
Notes regarding other children.
Do you have any physical or mental limitations that would require accommodations? *
Are you fleeing domestic violence? *
Do you have proof of pregnancy? *
A state ID is required at the first meeting.  Do you have one? *
How can A Mother's Hope best help you at this time in your life? *
Are you working with other agencies?  If so, which ones? *
What are your employment goals? *
Do you have any education goals?  If so, what are they? *
What is your current monthly income? *
From what source(s) do you receive your income? *
How did you hear about A Mother's Hope? *
Thank you for taking the time to fill out this application.  We will be in contact with you soon.
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