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Fatherheart Maternity Home in East Texas
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About
Our Story
Our Team
Testimonies
Our Programs
Fatherheart Maternity Home in East Texas
Pregnancy Resource Center
Building Blocks
Great Expectations Birthing Classes
GirlTalk
Loving Alternative
Mobile Pregnancy Resource Center
Get Involved
Volunteer
Youth With A Mission Staff
Events
Email Updates
Impact Stories
Shop & Support
Contact Us
Donate
Fatherheart Resident Application
Application for those seeking residency at Fatherheart
About You
Name
(Required)
Date of Birth
Referred By
Address
City
State
Zip
Current City
County
State
Zip
Home Phone
Cell Phone
Other Phone
Email
(Required)
Driver's License #
Driver's License Valid?
Please Select
Yes
No
Do You Have A Car?
Please Select
Yes
No
What is Your Insurance Company?
Age
Social Security #
Citizenship
Marital Status
Please Select
Single
Married
Engaged
Divorced
Separated
Other
Religious Affiliation
Are You Employed?
Please Select
Yes
No
Employer
Employer's Phone Number
Please Upload a Photo of Yourself
Max. file size: 256 MB.
Section 1
When was the first day of your last period?
Do you have an estimated due date?
Please Select
Yes
No
If yes, please list your due date.
Have you been pregnant before?
Please Select
Yes
No
If yes, did you:
Please Select
Parent
Place for Adoption
Abort
Miscarry
Other
Have you had prenatal care?
Please Select
Yes
No
County
State
Father of This Baby
Name
Are you in an ongoing romantic relationship with this baby's father?
Please Select
Yes
No
Are you in a friendship type of relationship with this baby's father?
Please Select
Yes
No
Do you feel safe in the relationship?
Please Select
Yes
No
Will your child be safe if you remain in the relationship?
Please Select
Yes
No
Does the father have any open court cases or is he in jail? Please explain:
Other Relationships
Are you in a romantic relationship with anyone other than the father of this baby?
Please Select
Yes
No
Will this person be involved In this baby's life?
Please Select
Yes
No
N/A
Do you feel safe in the relationship?
Please Select
Yes
No
Will your child be safe if you remain in the relationship?
Please Select
Yes
No
Children
Do you have dependent children?
Please Select
Yes
No
If Yes, please provide the following information for each child: Name/Age/Do you have custody?/Where will the child live while you are at Fatherheart?
Do you have an open CPS case? If Yes, please explain:
Do you have any other court cases unrelated to CPS (open or closed)? If Yes, please explain:
Section 2
Family Information/Emergency Contact
Mother's Name?
Phone Number
Father's Name?
Phone Number
If you have siblings, please provide their name(s) and phone number(s)
Do you live at home with your parents?
Please Select
Yes
No
How long has it been since you lived at home?
Do you have a good relationship with your family? Please explain:
Please provide the name and phone number for the person/people you would like to be an Emergency Contact
Section 3
At Fatherheart Maternity Home, we are committed to your education. Therefore, all residents who have not received a diploma or GED are required to go to school or at the discretion of our academic advisor work toward your GED while at the maternity home.
Where are you currently in your education?
Please Select
Currently Attending (not yet graduated from high school)
Graduated From High School
Dropped Out and Worked
Currently Enrolled in College/Vocational
Completed GED
Other
Last School Attended
Did you graduate?
Please Select
Yes
No
If No, what is the last year you attended?
Have you attended college?
Please Select
Yes
No
If Yes, what is your major?
Have you attended any other type of educational program? (ex: Trade School, Beauty/Barber School)
Please Select
Yes
No
If Yes, please list
Have you been diagnosed with any type of learning disorder?
Please Select
Yes
No
If Yes, what was the diagnosis?
Section 4
Medical & Assistance Information (if you are a minor, please have a parent complete this portion). Please Note: You must file separately for Pregnancy Medicaid, even if you are currently on Medicaid.
Primary Care Doctor
Phone
City of Primary Doctor
Do you have a Health Insurance ID#?
Please Select
Yes
No
If Yes, please list
Do you currently have a Pregnancy Medicaid in Texas ID#?
Please Select
Yes
No
If Yes, please list
If Yes, please list County
Are you currently on WIC?
Please Select
Yes
No
If Yes, please list County
Do you receive any other government assistance? Please explain
Have you had any medical problems during your pregnancy? Please explain
Have you had any medical problems unrelated to the pregnancy while you have been pregnant? Please explain
Have you seen a Physician during this pregnancy?
Please Select
Yes
No
Physician's Name
City
State
Have you ever been diagnosed with a chronic illness or disability? If yes, please explain
Are you currently on any prescription medications? If so, please list the name of the medication(s), how long you have been taking the medication(s) and what condition the medication(s) is treating.
Do you have any allergies?
Please Select
Yes
No
Do you take allergy medication (OTC)?
Please Select
Yes
No
Please list allergies and reaction type
Do you currently experience any of the following? Please select for each listed:
Depression
Please Select
Yes
No
Anxiety
Please Select
Yes
No
Alcohol Abuse
Please Select
Yes
No
Stealing
Please Select
Yes
No
Suicidal Thoughts
Please Select
Yes
No
Fire Setting
Please Select
Yes
No
Eating Disorders
Please Select
Yes
No
Mood Disorders
Please Select
Yes
No
Cruelty to Animals
Please Select
Yes
No
Cutting/Self Harm
Please Select
Yes
No
Child Abuse
Please Select
Yes
No
Physical Aggression
Please Select
Yes
No
Rape
Please Select
Yes
No
Drug Abuse
Please Select
Yes
No
Sexual Abuse
Please Select
Yes
No
Easily Angered
Please Select
Yes
No
Have you experienced any of the following? Please select for each listed:
Mental Health Issues
Please Select
Yes
No
Diabetes
Please Select
Yes
No
Developmental Disability
Please Select
Yes
No
HIV/AIDS
Please Select
Yes
No
Victim of Sexual Abuse
Please Select
Yes
No
Chronically Mentally Ill
Please Select
Yes
No
Unspecified Disability
Please Select
Yes
No
Tuberculosis
Please Select
Yes
No
Attention Deficit Disorder
Please Select
Yes
No
Asthma
Please Select
Yes
No
Allergies
Please Select
Yes
No
Physical Disability
Please Select
Yes
No
Victim of Domestic Violence
Please Select
Yes
No
Victim of Physical Abuse
Please Select
Yes
No
Special Needs
Please Select
Yes
No
Communicable Illness
Please Select
Yes
No
Lupus
Please Select
Yes
No
Other
Please Select
Yes
No
If you answered Yes to any of these, please comment or explain
Hospitalizations/Surgeries
Please describe any hospitalizations and/or surgeries you have had. Include the reason, date of hospitalization and any complications that have resulted from the sickness
Do you wear braces on your teeth?
Please Select
Yes
No
When was the last time you saw a dentist?
Do you have dental problems?
Please Select
Yes
No
If so, what problems are you having?
When was your last Optometrist Visit?
Please Select
Yes
No
Do you have any eye/vision related issues that hinder everyday living or cause pain?
Please Select
Yes
No
If Yes, please explain
Have You Used Any of the Following?
Alcohol
Please Select
Yes
No
First Time
Last Time
Marijuana
Please Select
Yes
No
First Time
Last Time
Cocaine/Crack
Please Select
Yes
No
First Time
Last Time
Heroin
Please Select
Yes
No
First Time
Last Time
Meth
Please Select
Yes
No
First Time
Last Time
Prescription Drugs
Please Select
Yes
No
First Time
Last Time
Pain Killers
Please Select
Yes
No
First Time
Last Time
Other
Please Select
Yes
No
First Time
Last Time
Do You Smoke?
Please Select
Yes
No
First Time
Last Time
Do You Vape?
Please Select
Yes
No
First Time
Last Time
Additional Comments
Have you ever received counseling for addiction, mental, or emotional issues?
Please Select
Yes
No
If Yes, please explain
Are you continuing to see a counselor?
Please Select
Yes
No
N/A
When was the last time you spoke with your counselor?
Is there additional information you would like for us to know concerning your health?
Section 5 - Parenting & Group Living
Fatherheart Maternity Home is a welcoming, loving place for women to be a part of a program that enriches their life and prepares them for the future. There are a variety of program opportunities offered that each resident will be expected to take advantage of and participate in while living in the home. To better know how to serve your specific needs, please answer the following:
While it may be too early to commit to what you plan to do after your child is born, please tell us what your initial thoughts are. Please select what you are leaning toward at this time.
Please Select
Parenting
Adoption
Undecided
How can we best help you make the best decision for both you and your child?
Please explain why you would like to live at Fatherheart Maternity Home.
Have you ever lived in a structured, group style of home?
Please Select
Yes
No
If Yes, please explain
How do you typically respond to authority?
Do you understand there are guidelines and authority figures that will be a part of the living experience at Fatherheart?
Please Select
Yes
No
Does that concern you?
Please Select
Yes
No
If Yes, please explain
How do your friends and family feel about your decision to live at Fatherheart?
Acknowledgments and Agreements
I understand Fatherheart Maternity Home will conduct a background check before I will be considered as a resident.
Please Select
Yes
No
I give Fatherheart Maternity Home permission to use the information I have provided to conduct a background check.
Please Select
Yes
No
I understand Fatherheart Maternity Home may conduct random drug testing while living in the home.
Please Select
Yes
No
I consent to random drug testing while living at Fatherheart Maternity Home as clarified in the Fatherheart Resident Handbook.
Please Select
Yes
No
I have read the Fatherheart Resident guidelines.
Please Select
Yes
No
I believe it is in the best interest for me and my unborn child to become a resident of Fatherheart Maternity Home. It is my intention to actively participate in the programs in place to benefit me and my unborn child.
Please Select
Yes
No
I request admission to the Fatherheart Maternity Home.
Please Select
Yes
No
