Application for Acceptance

This information is confidential. Please answer all questions honestly so we may know how best to help you.
Name:
Name you go by:
Email Address:

Current Living Situation:

Present Address:
Phone #:
Work Phone #:
Mother’s name:
Phone:
Father’s name:
Phone:
Name of Father of Baby:
Age of Father of Baby:

 

How long have you been with the Father of Baby?

 

FAMILY HISTORY

 

If you were raised by anyone other than your own parents, briefly explain:

Answer this section describing your own parents or parent substitute

Still living?

  • Father Yes No
  • Mother Yes No

 

Are your parents Christians? Yes No
For how long?

Denomination or type of church:
Father
Mother
Occupation:
Father
Mother

 

Are your parents still living together? Yes No

If not, cause for separation:

When separated?

Rate your parents’ marriage:
Unhappy
Average
Happy
Very Happy

As a child, did you feel closest to your
Father Mother Other

Rate your childhood life:
Very Happy
Happy
Average
Unhappy

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?

Status of relationships with:
Parents
Father of Baby
Family Members

 

Referred by:

 

INFORMATION ABOUT YOU

 

Date of Birth:
(in the form mm-dd-yyyy such as 12-23-1980)
Age:

 

City and State of Birthplace:
Social Security Number:

 

Are you a legal resident of the United States?
Yes No

Driver’s License Number (and expiration date)

 

PHYSICAL CHARACTERISTICS

 

Height
Weight
Eye Color
Hair Color

 

Marital Status:
Single
Married
Divorced
Separated

Children: Do you have any children? Yes No
If so, how many?

List Names and Ages:

Who has custody of your child(ren)?

 

EDUCATION

 

Name of last school attended:
Dates of attendance:

 

Did you graduate? Yes No
If not, last grade completed:

Do you plan on obtaining your GED while at Lifeline Family Center?
Yes No

 

MEDICAL

 

Name of Medical Provider:

Are you current on immunizations? Yes No

Have you had any medical issues in the last 5 years?
Yes No
If so, please list them:

Do you have any allergies? Yes No
List:

List any medications that you take:
Medication: Dosage:
Medication: Dosage:
Medication: Dosage:
List more medications here if needed:

Hospitalization History:

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
Explain:

List any physical limitations that you may have:

List all past surgeries (include dates):

 

PREGNANCY

 

Are you pregnant? Yes No
Approximate Due Date:

Has a doctor confirmed your pregnancy?
Yes No

Is the birth father aware of your pregnancy?
Yes No

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.

 

FINANCIAL

 

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

Carrier:
Policy #:

 

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#:

 

LEGAL BACKGROUND

 

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

How long?
Length of time remaining:
How often do you report?
In person or through mail?

 

Name of probation or parole officer:

Address:

Telephone #:

 

COUNSELING

 

Have you ever been to counseling? Yes No

When?
Where?
Purpose:
Doctor:

 

Have you ever received psychiatric care or been in a mental institution?
Yes No

When?
Where?
Date:
Program:
Address
City, State

 

Reason for leaving?

Age of first sex experience:
Forced Consent Yes No

Have you ever been a victim of rape or incest?
Yes No

Have you ever been involved in prostitution?
Yes No

Have you ever been involved in homosexuality?
Yes No

Have you ever tried to commit suicide?
Yes No
If so, when:

Why?

Have you ever used any of the following substances?

Alcohol Hallucinogenic (Acid, LSD, etc.)
Amphetamines (uppers) Heroin
Barbituates Inhalants (Glue, Paint Thinner, etc.)
Cocaine Marijuana
Crack Tobacco
Other

 

Why do you depend on drugs?
To cope with life
For pleasure
To escape reality
To be in with the crowd

Habit cost per day?
Longest period clean?

 

SPIRITUAL

 

Have you ever been involved in the following occult activities?

Astroprojection Satanic Worship
Divination Seances
Fortune Telling Spell Casting
Horoscope Tarot Cards
Levitation Voodoo
Ouiji Boards Witchcraft
Palm Reading Yoga

Write a brief explanation of your involvement with each:

Have you ever committed your life to God?
Yes No

Date:
Place:

 

What were the circumstances that led to this?

Denominational background:

Are you a member of any church or organization?
Yes No

Which One?

How often do you attend church?

Do you read the Bible?
Yes No
How often?

Do you ever pray?
Yes No
How often?

Do you feel that you have a need for God?
Yes No
Explain:

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.

 

By:
Date:
(in the form mm-dd-yyyy such as 12-23-2011)

 

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.