Solve Resident Intake Application

A. Demographic Information

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Marital status *
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Do you have any disabilities that require reasonable accommodations? *
My current pregnancy plans include: *
Does the baby's father know about the baby? *
Is the baby's father supportive? *
Is he supporting you financially? *
Do your parents know you are pregnant? *
Are your parents supportive? *
Your Parents' Marital Status: *
Mother's Status *
Father's Status *
Step Parent Status
Number of Brothers *
Number of Sisters *
Do you have any other children? *
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Active

B. Education & Training

Do you have a high school diploma? *

C. Employment & Financial Status

Please Mark ALL Sources of Income:
 Amount ReceivedLength of Time Receiving
Family Help
Wages
Public Assistance
Supplemental Security Income (SSI)
Social Security Disability Income (SSDI)
Are you receiving Medicaid? *
Are you receiving WIC? *
Are you receiving Foodstamps? *
Do you have a checking account? *
Do you have a savings account? *
Do you have any of these outstanding debts? *

D. Legal History

Do you have a police record? *
Are you currently on Probation or Parole? *
Are you on file for child abuse or have you ever been convicted of a child abuse crime? *

E. Behavioral / Social / Emotional Health

Have you ever been told that you exhibit symptoms of any of the following: *
 YesNoNot formally diagnosed
ADD
ADHD
Anxiety Disorder
Bipolar Disorder
Borderline Personality Disorder
Depression
Eating Disorders
Obsessive Compulsive Disorder
PTSD
Schizophrenia
Have you been in counseling or therapy of any kind? *
Have you ever been a victim of domestic violence? *
Have you ever been a victim emotional, physical, or sexual abuse? *
Have you ever inflicted self-injury such as cutting, bingeing, purging, etc? *
Have you ever had any psychiatric treatment or counseling? *
Have you had any thoughts, gestures, incidents, or attempts at suicide? *

F. Substance Use

Tell us about your usage of the following items: *
 NoneOccasionallyWeeklyDaily
Cigarettes
Loose Tobacco
Alcohol
Recreational drugs
Methodone / Suboxone
Do you identify as an alcoholic? *
Do you identify as a drug addict? *
Are you currently or have you ever been in recovery for drugs or alcohol? *

G. Housing Information

Have you lived in a housing program before? *

H. Pregnancy Information

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Normal *
Birth Control *
Discontinued? *
Number of personal pregnancies
 Carried to termMultiplesMiscarriage / StillbirthAbortionAdoption
Previous pregnancy 1
Previous pregnancy 2
Previous pregnancy 3
Are you currently under medical care for this pregnancy? *
Please mark all symptoms you have experienced with this pregnancy: *
 NoneOccasionallyWeeklyDaily
Nausea
Vomiting
Spotting
Vaginal Discharge
Kidney
Headaches
Dizziness
Fatigue
Blurred Vision
Swelling Hands/Feet

I. Medical History & Information

Do you have any known allergies to environment, food, medications or exposures? *
Current medications & supplements - please include vitamins and OTC medications
 NameDoseHow long have you been taking?
1
2
3
4
5
Please mark the medical conditions that apply to you or any immediate family member.
 MyselfMotherFatherFamily history
Epilepsy
Thyroid Condition
Scarlet Fever
Meningitis
Infectious Mononucleosis
Tuberculosis TB
Exposure to TB
Malaria
Bronchitis
Pneumonia
Pleurisy
Hepatitis (yellow jaundice)
Bladder Infections
Rheumatic Fever
Kidney Disease
Sickle Cell Anemia
Hives
Hay Fever/Sinusitis
Asthma
Emphysema
Arthritis
Back trouble
High Blood Pressure
Heart Disease
Anemia
Bleeding Tendency
Nose Bleeds
Ulcer
Cancer
Hemorrhoids
Blood Transfusion
Diabetes
Multiple Births
Hospitalization
Psychological Problems
Food Allergies
Environmental Allergies
Drug Allergies
Substance Abuse

J. Getting to know you

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? *

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