• Family-Focused Care Initial Inquiry

    Family-Focused Care Initial Inquiry

  • NOTE: This initial inquiry is for MOTHERS WITH CHILDREN.
    If you need to place a child age 6-17 into child-focused residential care, please use this form instead: Child-Focused Application.

  • Location Preference

    By checking your placement location preference below we will know how to best direct your application.

  • Which location would you prefer?*
  • How did you find out about our services/program?*

  • General Information

  • Date of Birth*
     - -
  •  -
  • Contact Phone Type*
  • Marital Status*

  • Spouse/Boyfriend/Child(ren)'s Fathers

  • Your Family

    Please give as much information and details as possible.

  • Physical & Mental Health

  • Have you ever had a psychological evaluation?*

  • Substance Abuse

  • Do you currently use drugs or alcohol?*
  • If yes, please check any that apply.*
  • Have you ever used drugs or alcohol?*
  • Do you currently use tobacco products? (vape/ecig/cigarettes/etc)*

  • Legal

  • Have you ever been charged with or convicted of a crime (felony/misdemeanor)?*

  • Are you on probation?*
  • Are you in any legal trouble?*

  • Your Children

  • Are You Pregnant?
  • Tell us about your children.*

  • Transportation

  • Do you have a working vehicle?*

  • Assistance

  • Do you receive Social Security Benefits (Including SSD/SSI)*

  • Notification Preference

    As a courtesy, we would like to notify you of the initial status of your inquiry. Once the campus reviews your initial inquiry, they will be contacting you. Please indicate your preference of contact.
  • Follow-Up Contact Preference*
  • Should be Empty: