Resident Initial Inquiry
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Contact LifeHouse
First Name
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Last Name
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Email
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Phone
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Date of Birth
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Zip Code
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Has your current pregnancy been confirmed by a doctor?
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-choose one-
Yes
No
How far along in your pregnancy are you? (# of weeks)
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Describe your current housing situation.
Do you have custody of any biological children? (if yes, list age & gender)
Do you have a history of substance abuse / addiction? (explain)
If you answered yes to the previous question what is the length of your current maintained sobriety?
If applicable when was your last re-occurrence of usage?
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Do you have a history of mental health / wellness issues? (explain)
Do you have a criminal background?
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Yes
No
If you answered yes to the previous question please list the nature of your offense(s) and conviction date.
Do you have a desire to work post-delivery? What is the industry of your previous work experience?
Would you like to be contacted by a LH staff member to further discuss the above information and/or additional program requirements?
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Yes
No
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