Current Living Situation:
How long have you been with the Father of Baby?
If you were raised by anyone other than your own parents, briefly explain:
Answer this section describing your own parents or parent substitute
Are your parents Christians? Yes No
For how long?
Are your parents still living together? Yes No
If not, cause for separation:
Rate your parents’ marriage:
As a child, did you feel closest to your
Father Mother Other
Rate your childhood life:
How many brothers and sisters do you have?
How many OLDER brothers or sisters do you have?
Siblings of client (state names & ages):
Do you and your parents get along?
Are you a legal resident of the United States?
Driver’s License Number (and expiration date)
Children: Do you have any children? Yes No
If so, how many?
List Names and Ages:
Who has custody of your child(ren)?
Did you graduate? Yes No
If not, last grade completed:
Do you plan on obtaining your GED while at Lifeline Family Center?
Name of Medical Provider:
Are you current on immunizations? Yes No
Have you had any medical issues in the last 5 years?
If so, please list them:
Do you have any allergies? Yes No
List any medications that you take:
List more medications here if needed:
Lifeline Family Center does not have the medical personnel to monitor the administration of psychotropic drugs. If you are on these medications, we will need a note from the attending physician stating that you are able to function daily while off these medications.
Are you on a special diet? Yes No
List any physical limitations that you may have:
List all past surgeries (include dates):
Are you pregnant? Yes No
Approximate Due Date:
Has a doctor confirmed your pregnancy?
Is the birth father aware of your pregnancy?
Lifeline Family Center firmly believes in allowing you to make the choice between adoption and parenting. We believe that while you are here, God will give you direction for your life and that of your unborn child.
Do you have any outstanding debt? Yes No
What arrangements will you make for their payment while you are at home?
Do you have medical insurance? Yes No
Do you have Medicaid? Yes No
Address you used to apply for Medicaid?
How did you apply for Medicaid? Online or In Person?
If you have Medicaid, please list your Medicaid ID#:
Have you ever been arrested? Yes No
How many times:
Dates, charges, etc.:
Have you ever been on probation or parole? Yes No
Are you now? Yes No
Name of probation or parole officer:
Have you ever been to counseling? Yes No
Have you ever received psychiatric care or been in a mental institution?
Reason for leaving?
Age of first sex experience:
Forced Consent Yes No
Have you ever been a victim of rape or incest?
Have you ever been involved in prostitution?
Have you ever been involved in homosexuality?
Have you ever tried to commit suicide?
If so, when:
Have you ever used any of the following substances?
Why do you depend on drugs?
To cope with life
To escape reality
To be in with the crowd
Have you ever been involved in the following occult activities?
Write a brief explanation of your involvement with each:
Have you ever committed your life to God?
What were the circumstances that led to this?
Are you a member of any church or organization?
How often do you attend church?
Do you read the Bible?
Do you ever pray?
Do you feel that you have a need for God?
What is your present relationship with God?
Briefly Answer the Following Questions:
1. What is the main problem, as you see it? (why are you here?)
2. What have you done about it?
3. What can we do?
4. As you see yourself, what kind of person are you? Describe yourself:
5. Is there any other information we should know?
6. Why would you like to come to Lifeline Family Center?
7. What would you like to see happen in your life while in this home?
8. What do you do when you get angry?
9. What do you do when you are sad?
Please bring a certified Birth Certificate or a State I.D. and a Social Security Card if you decide to move in.
IMPORTANT: Prior to admittance into our program, we require you to have a TB test with written results. You are also required to take a drug test at the time of entry in the program.
Changing the world...
two lives at a time.
907 SE 5th Avenue
Cape Coral, Florida 33990
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