Solve Resident Intake Application

A. Demographic Information

First Name *

Middle Name *

Last Name *

Estimated Due Date * +

Marital status *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Social Security Number * 🛈

Current Age *

Date of Birth: * +

Place of Birth *

Your Identifying Race *

Hair Color *

Height *

Eye Color *

Referred By

Do you have any disabilities that require reasonable accommodations? *

Yes

No

If yes, please specify

My current pregnancy plans include: *

Parenting

Adoption

Undecided

Does the baby's father know about the baby? *

Yes

No

Is the baby's father supportive? *

Yes

No

Please explain:

Is he supporting you financially? *

Yes

No

If so, how much per month?

Baby's Father's Name *

His Age *

Street Address

Address Line 2

City

State

Zip Code

Phone Number

Occupation

Do your parents know you are pregnant? *

Yes

No

Are your parents supportive? *

Yes

No

Your Parents' Marital Status: *

Married

Divorced

Separated

Your Mother's Name *

Phone Number

Mother's Status *

Alive

Deceased

Estranged

Street Address

Address Line 2

City

State

Zip Code

Occupation

Your Father's Name *

Phone Number

Father's Status *

Alive

Deceased

Estranged

Street Address

Address Line 2

City

State

Zip Code

Occupation

Your Step Parent's Name

Phone Number

Step Parent Status

Alive

Deceased

Estranged

Street Address

Address Line 2

City

State

Zip Code

Occupation

Number of Brothers *

Ages

Number of Sisters *

Ages

Extended Family Member Support - Name & Relationship

Emergency Contact *

Contact Phone *

Relationship *

Do you have any other children? *

Yes

No

Child's Name

Child's Birthdate +

Where is Child?

Child's Name

Child's Birthdate +

Where is Child?

Child's Name

Child's Birthdate +

Where is Child?

Church Affiliation

Active

Yes

No

Pastor's Name

Church phone number

B. Education & Training

Last School Attended *

City / State / Zip *

Last grade completed *

Do you have a high school diploma? *

Yes

No

If you quit school prior to graduation, why?

What are your career / vocational goals?

C. Employment & Financial Status

Employment Status *

Last or Current Employer

Length of Current Employment

Address of employer

Job Description

Please Mark ALL Sources of Income:

	Amount Received	Length of Time Receiving
Family Help	Amount Received	Length of Time Receiving
Wages	Amount Received	Length of Time Receiving
Public Assistance	Amount Received	Length of Time Receiving
Supplemental Security Income (SSI)	Amount Received	Length of Time Receiving
Social Security Disability Income (SSDI)	Amount Received	Length of Time Receiving

Are you receiving Medicaid? *

Yes

No

Have Applied

Are you receiving WIC? *

Yes

No

Have Applied

Monthly amount received?

Are you receiving Foodstamps? *

Yes

No

Have Applied

Monthly amount received?

Do you have a checking account? *

Yes

No

Current Balance

Do you have a savings account? *

Yes

No

Current Balance

Do you have any of these outstanding debts? *

Please explain

D. Legal History

Do you have a police record? *

Yes

No

If yes, please describe charges:

Are you currently on Probation or Parole? *

Yes

No

Name and Address of Parole / Probation Officer

Are you on file for child abuse or have you ever been convicted of a child abuse crime? *

Yes

No

If yes, please explain

E. Behavioral / Social / Emotional Health

Have you ever been told that you exhibit symptoms of any of the following: *

	Yes	No	Not formally diagnosed
ADD	Yes	No	Not formally diagnosed
ADHD	Yes	No	Not formally diagnosed
Anxiety Disorder	Yes	No	Not formally diagnosed
Bipolar Disorder	Yes	No	Not formally diagnosed
Borderline Personality Disorder	Yes	No	Not formally diagnosed
Depression	Yes	No	Not formally diagnosed
Eating Disorders	Yes	No	Not formally diagnosed
Obsessive Compulsive Disorder	Yes	No	Not formally diagnosed
PTSD	Yes	No	Not formally diagnosed
Schizophrenia	Yes	No	Not formally diagnosed

Have you been in counseling or therapy of any kind? *

Yes

No

If yes, please provide the name and phone number of your counselor or therapist

Have you ever been a victim of domestic violence? *

Yes

No

Unsure

Have you ever been a victim emotional, physical, or sexual abuse? *

Yes

No

Unsure

Have you ever inflicted self-injury such as cutting, bingeing, purging, etc? *

Yes

No

Unsure

Have you ever had any psychiatric treatment or counseling? *

Yes

No

Unsure

Have you had any thoughts, gestures, incidents, or attempts at suicide? *

Yes

No

Unsure

If yes to any of the above listed questions, please explain:

Please list all medications you have been or are currently on for mental health support:

F. Substance Use

Tell us about your usage of the following items: *

	None	Occasionally	Weekly	Daily
Cigarettes	None	Occasionally	Weekly	Daily
Loose Tobacco	None	Occasionally	Weekly	Daily
Alcohol	None	Occasionally	Weekly	Daily
Recreational drugs	None	Occasionally	Weekly	Daily
Methodone / Suboxone	None	Occasionally	Weekly	Daily

Do you identify as an alcoholic? *

Yes

No

If yes, what is your alcohol of choice?

Last used?

Do you identify as a drug addict? *

Yes

No

If yes, what is your drug(s) of choice?

Last used?

Are you currently or have you ever been in recovery for drugs or alcohol? *

Yes

No

What is your longest time being chemically free?

Please describe your feelings towards your drug and alcohol use:

G. Housing Information

Have you lived in a housing program before? *

Yes

No

What program were you in and why?

Dates and Length of Time in Housing:

Please provide a brief explanation of your previous housing program experiences.

H. Pregnancy Information

Date of last menstrual cycle? * +

Normal *

Yes

No

Age began? *

Length of Cycle?

Days in Cycle?

Birth Control *

Yes

No

Type of Birth Control

Discontinued? *

Yes

No

N/A

Number of personal pregnancies

	Carried to term	Multiples	Miscarriage / Stillbirth	Abortion	Adoption
Previous pregnancy 1	Carried to term	Multiples	Miscarriage / Stillbirth	Abortion	Adoption
Previous pregnancy 2	Carried to term	Multiples	Miscarriage / Stillbirth	Abortion	Adoption
Previous pregnancy 3	Carried to term	Multiples	Miscarriage / Stillbirth	Abortion	Adoption

Are you currently under medical care for this pregnancy? *

Yes

No

Have an appointment but have not been seen

Name of Physician or Medical Clinic Provider

Phone Number

Street Address

City

State

Zip

Please mark all symptoms you have experienced with this pregnancy: *

	None	Occasionally	Weekly	Daily
Nausea	None	Occasionally	Weekly	Daily
Vomiting	None	Occasionally	Weekly	Daily
Spotting	None	Occasionally	Weekly	Daily
Vaginal Discharge	None	Occasionally	Weekly	Daily
Kidney	None	Occasionally	Weekly	Daily
Headaches	None	Occasionally	Weekly	Daily
Dizziness	None	Occasionally	Weekly	Daily
Fatigue	None	Occasionally	Weekly	Daily
Blurred Vision	None	Occasionally	Weekly	Daily
Swelling Hands/Feet	None	Occasionally	Weekly	Daily

If you have experienced any complications with this pregnancy, please explain:

I. Medical History & Information

Do you have any known allergies to environment, food, medications or exposures? *

Yes

No

Please list all allergies that are known to you.

Current medications & supplements - please include vitamins and OTC medications

	Name	Dose	How long have you been taking?
1	Name	Dose	How long have you been taking?
2	Name	Dose	How long have you been taking?
3	Name	Dose	How long have you been taking?
4	Name	Dose	How long have you been taking?
5	Name	Dose	How long have you been taking?

Please mark the medical conditions that apply to you or any immediate family member.

	Myself	Mother	Father	Family history
Epilepsy	Myself	Mother	Father	Family history
Thyroid Condition	Myself	Mother	Father	Family history
Scarlet Fever	Myself	Mother	Father	Family history
Meningitis	Myself	Mother	Father	Family history
Infectious Mononucleosis	Myself	Mother	Father	Family history
Tuberculosis TB	Myself	Mother	Father	Family history
Exposure to TB	Myself	Mother	Father	Family history
Malaria	Myself	Mother	Father	Family history
Bronchitis	Myself	Mother	Father	Family history
Pneumonia	Myself	Mother	Father	Family history
Pleurisy	Myself	Mother	Father	Family history
Hepatitis (yellow jaundice)	Myself	Mother	Father	Family history
Bladder Infections	Myself	Mother	Father	Family history
Rheumatic Fever	Myself	Mother	Father	Family history
Kidney Disease	Myself	Mother	Father	Family history
Sickle Cell Anemia	Myself	Mother	Father	Family history
Hives	Myself	Mother	Father	Family history
Hay Fever/Sinusitis	Myself	Mother	Father	Family history
Asthma	Myself	Mother	Father	Family history
Emphysema	Myself	Mother	Father	Family history
Arthritis	Myself	Mother	Father	Family history
Back trouble	Myself	Mother	Father	Family history
High Blood Pressure	Myself	Mother	Father	Family history
Heart Disease	Myself	Mother	Father	Family history
Anemia	Myself	Mother	Father	Family history
Bleeding Tendency	Myself	Mother	Father	Family history
Nose Bleeds	Myself	Mother	Father	Family history
Ulcer	Myself	Mother	Father	Family history
Cancer	Myself	Mother	Father	Family history
Hemorrhoids	Myself	Mother	Father	Family history
Blood Transfusion	Myself	Mother	Father	Family history
Diabetes	Myself	Mother	Father	Family history
Multiple Births	Myself	Mother	Father	Family history
Hospitalization	Myself	Mother	Father	Family history
Psychological Problems	Myself	Mother	Father	Family history
Food Allergies	Myself	Mother	Father	Family history
Environmental Allergies	Myself	Mother	Father	Family history
Drug Allergies	Myself	Mother	Father	Family history
Substance Abuse	Myself	Mother	Father	Family history

Comments or other medically-relevant issues:

J. Getting to know you

Please write a brief statement about why you need housing: *

What are the ways that you believe Solve can best help you? *

What are some of the challenges that you would like to overcome while you are at Solve? *

What are your strengths? *

How do you plan on becoming prepared for your exit from Solve? *

Some of the basic Expectations / Responsibilities of a resident at Solve include the following. Please mark your agreement with each item listed or leave blank those you have questions about.

Do you have any questions regarding any of the listed expectations or foresee difficulty in adjusting to these requirements? *

Yes

No

Not Sure

Please list any concerns you would like to discuss regarding the above referenced Expectations / Responsibilities: *

All Solve residents work with our staff case managers and counselors. What benefits do you expect to receive through these offerings? *

Please write a brief autobiography. An autobiography is the story about your life. It provides information about your family of origin and some of the things you remember about your childhood, adolescent and early adult life. Some things to think about as you are writing include: What was your relationship to your mother, father, sibling(s) like? Were there activities you enjoyed participating in as a family? How did your parents relate to one another? Were you or a family member ever abused? What level of education have you received? What have you learned about life and what do you look forward to in the future? *

K. Release of Information

I understand that Solve may need to obtain medical and mental health records as part of my application process. I am willing to complete a Release of Information form as part of my intake. *

Yes

No

I understand that Solve Maternity Homes is a Voluntary Program and operates with Resident Expectations & Policies and Procedures in place for organized structure. I will be given an opportunity to review completely these expectations and clarify understanding prior to signing in agreement. *

Yes

No

I certify that the information I have provided above is accurate to the best of my knowledge. *

clear

Date of Applicaton * +

Adhering to Curfew	Receiving Direction	Respectful Group Living
Following Policies & Procedures	Case Management Attendance	Counseling Attendance
Church / Bible Study Attendance	Life-skills Class Attendance	Completing Assigned Chores
Preparing Meals	Managing Personal Schedule	Pursuing Educational Goals
Gaining or Maintaining Employment	Maintaining Good Hygiene	Acquiring Housing for Exit Plan