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Form Submission is restricted

Your Resident Application for Hannah's Home is successfully submitted. Thank you!

I. Background Information

First Name:

Last Name:

Middle Name:

Date of Birth:

Age:

Social Security #:

Height:

Weight:

Eye Color:

Hair Color:

Marital Status:

Single

Married

Divorced

Separated

Widowed

Street Address:

City:

State:

Zip Code:

Phone:

Driver's License?

Number and Expiration Date:

Insurance?

Agency and Proof of Insurance:

Emergency Contact #1:

Relation:

Street Address:

City:

State:

Zip Code:

Phone:*

Emergency Contact #2:

Relation:

Street Address:

City:

State:

Zip Code:

Phone:

When is admission needed?

II. Family History

Who were you raised by?

Biological Mother

Biological Father

Adopted Mother

Adopted Father

Grandparents

Other

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

Mother's Name:

Street Address:

City:

State:

Zip Code:

Phone:

Highest Grade Completed:

Occupation:

Father's Name:

Street Address:

City:

State:

Zip Code:

Phone:

Highest Grade Completed:

Occupation:

Are your parents...

Married/Living together

Divorced

Never Married

Married not living together

Deceased

If deceased, which parent?

If parents are separated, what was the cause?

When did the separation occur?

What are three words to describe your mother?

What are three words to describe your father?

As a child, did you feel closest to your mother or father?

Please rate your parent's marriage:

Happy

Average

Unhappy

Please rate your childhood:

Very Happy

Happy

Average

Unhappy

How many brothers and sisters do you have?

Please list names and ages of all siblings:

III. Demographics

NOTE: The following information is used for statistical purposes only

Ethnic Categories:

Hispanic or Latino

Non-Hispanic or Latino

Racial Categories:

American Indian or Alaska Native

Asian

Black or African American

White

Other

IV. Financial

NOTE: This information is for us to help you budget and will not keep you from being accepted

List all income/aid you currently receive (food stamps, government assistance programs, etc.):

List any monthly bills you are currently responsible for paying:

Do you have any outstanding debt (credit cards, personal loans, etc.)? If yes, please list names and amounts:

Do you think you generally manage your money well?

What arrangements will you make for these payments while you are at Hannah's Home?

V. Status

Do you have a child now?

If yes, how many?

Gender of children?

Names and ages of children:

Who currently has custody of your children?

Name:

Phone:

VI. Current Housing

Current Living Situation:

Homeless

In a shelter

Living with parent(s)

Living with relative(s)

Living with friend(s)

Describe your current living situation (shelter, apartment of your own, apartment of someone else’s) and your relationship to the other people living with you:

How long have you lived in your current situation?

Are you paying bills where you currently live?

Why do you want to leave your current living situation?

How many times have you moved within the last two years and for what reason(s)?

Is your current living situation unsafe for you and/or your baby?

Yes

No

If yes, please explain:

VII. Father of the Child

Father of Child:

Age:

Street Address:

City:

State:

Zip Code:

Phone:

Race:

Is he employed?

Yes

No

If yes, where?

Please list the father’s current education status:

Does the father currently use drugs or alcohol?

Yes

No

Does the father have a history of drug or alcohol use?

Yes

No

Does the father have any legal issues (past or pending) or any involvement with law enforcement?

Yes

No

If yes, please explain:

Is he aware of your pregnancy?

Yes

No

If yes, what are his thoughts about the pregnancy?

Do the father’s parents know about the pregnancy?

Yes

No

If yes, what are their thoughts about the pregnancy?

Current relationship with baby’s father:

Very close/supportive

Close/somewhat supportive

Not close/not supportive

Never see him

When, where, and how did you meet the father of your baby?

VIII. Education/Employment

Please check which one applies:

In school

Graduated from high school

Earned GED

Not in school, no degree

If enrolled, name of school:

Current grade level:

Phone:

Contact:

Current GPA:

What is the highest grade you completed?

Name of last school attended:

Phone:

Contact:

Dates of Attendance:

Please list any school issues (excessive absences, suspensions, fighting, poor grades, etc.):

What are your long-term educational goals?

What do you see as a barrier for achieving your educational goals?

What do you see as your strengths for achieving these goals?

What is your ideal job?

Are you currently employed?

Yes

No

If yes, where?

For how long?

Please list last four jobs (most recent to latest), location, duration, and reason for leaving:

IX. Counseling

Have you ever been to counseling?

Yes

No

If yes, when?

Where?

Purpose:

Doctor/Counselor:

Have you ever received psychiatric care or been in a mental institution?

Yes

No

If yes, when?

Where?

Have you ever attended a religious or non-religious program?

Yes

No

Date:

Program Name:

Address:

Reason for leaving:

Age of first sexual experience:

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?

Why?

X. Legal

NOTE: Having past/present legal problems will not automatically exclude you from the program

Do you have any present legal problems?

Yes

No

If yes, please list all legal problems:

Please list all charges and arrests (with year, age, and result to you) including adult, juvenile, traffic, and DUI:

Are there any current warrants out for your arrest?

Yes

No

If yes, please explain:

Are you currently under probation/parole supervision?

Yes

No

If yes, what is the name and phone number of your probation/parole officer?

How often do you report to them?

In-person or via mail?

XI. Substance Use

NOTE: This information is confidential and may not exclude you from admission into Hannah's Home

Are you currently using or have used any of the following (check those that apply):

Amphetamines (uppers)

Heroin

Barbiturates

Cocaine

Crack

Inhalants (glue, paint thinner, etc.)

Marijuana

Tobacco

Hallucinogenic (acid, LSD, etc.)

Alcohol

Other

Please include age of first use, how often, amount used, and date of last use:

Have you used drugs/alcohol while pregnant?

Yes

No

If yes, what did you use and how often?

Why did you feel the need to turn to drugs? (Check all that apply)

To cope with life

To escape reality

For pleasure

To be in with the crowd

Other

Have you experienced failed attempts to stop using/drinking or cutting down?

Yes

No

Have you experienced failed attempts to stop using or cutting down, despite being pregnant?

Yes

No

If yes, please explain:

Habit cost per day?

Longest period clean?

Have you ever been in a Substance Abuse Treatment Facility?

Yes

No

If yes, please list names and dates of attended treatment programs:

XII. Pregnancy Information

Is this your first pregnancy?

Yes

No

Have you had a pregnancy test?

Yes

No

If no, what was the outcome?

Live birth

Miscarriage

Pregnancy terminated

If you have another child, where is the child living?

Have you received prenatal care?

Yes

No

Date of last doctors appointment:

Is your pregnancy considered high-risk?

If yes, please explain:

Are there any medical concerns for you and/or your baby?

Yes

No

If yes, please explain:

Expected due date:

Would you like to receive counseling to consider adoption?

Yes

No

XIII. Health Information

Name of doctor:

Phone:

Address:

Are your immunizations up to date?

Do you have any of the following problems?

Visual problems

Speech problems

Hearing problems

If yes, please explain:

Please describe any physical problems you may have (back pain, chronic headaches, diabetes, asthma, hepatitis, HIV+, STDs, etc.):

Do you receive medical treatment for problems indicated?

Yes

No

If yes, where?

Name of dentist or clinic:

Phone:

When was the last time you went to the dentist?

Are you having any dental problems now?

Yes

No

If yes, please describe:

Name of eye doctor:

Phone:

When was the last time you went to the eye doctor?

Do you wear glasses or contact lenses?

Yes

No

Do you have allergies?

Yes

No

If so, please list:

Are you currently taking any prescription medication?

Yes

No

If yes, please list them and the dosage:

NOTE: Hannah’s Home 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 your attending physician stating that you are able to function daily while off these medications.

Are you on a special diet?

Yes

No

If yes, please explain:

Please list any physical limitations that you may have:

Please list all past surgeries you may have had including dates:

Birth to Present Medical History (check all that apply):

Birth defects

Asthma

Anemia

Blood disorder

Cancer

Diabetes (Type 1)

Diabetes (Type 2)

Epilepsy

HIV/AIDS

Kidney disease

Heart disease

Hemophilia

Liver disease

Pneumonia

Seizure

Sexually transmitted disease

Skin disease

Sleep disturbance

Diphtheria

Measles

Mumps

Rheumatic fever

Scarlet fever

Small pox

Tuberculosis

Typhoid

Whooping cough

If so, please explain, list date of onset, and current treatment to date:

Have you ever experienced any of the following?

Night terrors

Sleep walking

Hallucinations

Delusions

Hearing voices

Night sweats

Fear of the dark

Insomnia

Fear of bedtime

Difficulty walking

Enuresis

Coma

Spinal injury

Back pain/injury (muscular)

Head trauma or injury

Broken bones (please explain in detail below)

Bowel trouble (impaction, obstruction, loose)

Kidney trouble

UTI (list frequency and cause below)

If so, please list behaviors associated with each problem:

Have you ever experienced any of the following?

Conjunctivitis

Nail fungus

Foot fungus

Warts

Frequent bloody nose

Cuts or sores that won't heal

Bleeding tendencies

Frequent thirst

Fainting

Periods of unconsciousness

Frequent colds/flu

Sinusitis

Ear, nose, or throat trouble

Running ears

Clogged ears

Difficulty hearing

Hearing loss

Vision trouble

Eye trouble

Hepatitis A

Hepatitis B

Hepatitis C

Shortness of breath

Heart murmur

Stroke

Jaundice

Stomach trouble

Ulcers

Tumor

Appendicitis

Hernia

Swollen/painful joints

XV. Spiritual

Have you ever been involved in the following activities (check all those that apply):

Astral projection

Divination

Fortune telling

Horoscope

Levitation

Ouiji boards

Palm reading

Satanic worship

Séances

Spell casting

Tarot cards

Voodoo

Witchcraft

Yoga

None of the above

Please write an explanation of your involvement with each:

Have you ever been in any of the following groups?

Christian Science

Eastern Religion

Jehovah's Witness

Brotherhood

Mormonism

Scientology

Transcendental Meditation

New Age Movement

None of the above

Please write a brief explanation of your involvement with each:

What are your immediate thoughts when you hear the word “God” or “Jesus”?

Have you ever committed your life to God?

Date:

Place:

What were the circumstances that led to this?

Denominational background:

Are you a member of any church or organization?

If so, which one?

How often do you attend church?

Do you read the Bible?

If so, how often?

Do you ever pray?

If so, how often?

Do you feel that you have a need for God?

Please explain:

What is your present relationship with God?

XVI. Essay (Please answer the following questions fully and truthfully)

What is the main problem in your opinion (i.e. why are you here?)

What have you done about it thus far?

What can we do to help?

What makes you excited about residing at Hannah’s Home?

What makes you nervous or hesitate about residing at Hannah’s Home?

What kind of person are you and how do you see yourself?

Why would you like to come to Hannah’s Home?

What would you like to see happen in your life while staying at Hannah's Home? Please list three specific goals.

How do you feel about residing in a Christian-based program which involves Bible studies, Church attendance, and Biblical-based classes?

Is there any other information we should know?

I have accurately indicated all of the information pertaining to my situation, condition, and family needs. Any falsified information may cause my application and/or subsequent acceptance to be re-evaluated and/or suspended.

Email Address*

Your signature:*

Date:*

Hannah’s Home of South Florida provides a safe and loving Christian environment for single pregnant young women.

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Hannah’s Home of South Florida

Address:
PO BOX 4512
Tequesta, Florida 33469

Phone: (561) 277-9823

Email: hhsf@hannahshomesf.org

© 2023 Hannah's Home. All rights reserved.

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