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?*

Family Focused Care at BCH (Owasso)Family Focused Care at The Vine (OKC)No Location Preference / First Available (Submits to both locations.)
How did you find out about our services/program?*

FamilyFriendOBHC StaffCaseworkerTherapist/CounselorPastorShelterOther
General Information
Name*

First NameMiddle (optional)Last Name
Date of Birth*

MonthDayYear
Age*
(Adult applicant)
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary (Contact) Phone Number*

Area CodePhone Number
Contact Phone Type*

HomeWorkCellFriend
Email*
example@example.com
Marital Status*

WidowedNever MarriedDivorcedMarried but SeparatedOther
Spouse/Boyfriend/Child(ren)'s Fathers
Describe your relationship with your spouse/boyfriend/child(ren)'s fathers.*
Please include all.
Your Family

Please give as much information and details as possible.
Explain your family's circumstances and why you are needing help.*
Physical & Mental Health
Have you ever had a psychological evaluation?*

YesNo
If yes, please explain:*
What was the diagnosis?
Are you currently taking prescription and/or over the counter medications? *
Please list all medications and purpose for taking the medication (example: drug name: ibuprofen, reason: arthritis)
What hospitalizations have you had and when?*
Substance Abuse
Do you currently use drugs or alcohol?*

YesNo
If yes, please check any that apply.*

Alcohol SometimesAlcohol OftenDrugs SometimesDrugs Often
Have you ever used drugs or alcohol?*

YesNo
Do you currently use tobacco products? (vape/ecig/cigarettes/etc)*

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

Yes (misdemeanor)Yes (felony)NoOther
Are you on probation?*

YesNo
Are you in any legal trouble?*

YesNo
Please provide details of legal issues/involvement:*
Explain for all. Include court, charges, convictions, probations or other any other legal trouble. If none, write "none."
If you have a DHS/ICW case, what is your caseworker's name and contact information?*
If none, write "none."
Your Children
Are you pregnant?*

Yes, I am pregnantNo, I am not pregnant
How far along are you in your pregnancy?*
If you are pregnant and seeing a doctor, what is the name and address of the doctor?*
If not seeing a doctor, type "n/a".
Child(ren)'s Information*
Transportation
Do you have a working vehicle?*

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

YesNo
If yes, please provide amount:*
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*

PhoneEmail
Should be Empty:

Family Focused Care Initial Inquiry

General Information

Spouse/Boyfriend/Child(ren)'s Fathers

Your Family

Physical & Mental Health

Substance Abuse

Legal

Your Children

Transportation

Assistance

Notification Preference