Mountain House Application - So Big

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Thank you for taking the time to fill out our Application for Admission.
PLEASE REMEMBER ALL INFORMATION PROVIDED IS CONFIDENTIAL!
**An applicant providing false information or omitting information may not be considered.**

Mountain House - Resident Application for Admission

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

County *

Email *

Phone Number *

Present Age *

Date of Birth *

Place of Birth *

Social Security Number *

With Whom are You Currently Living? *

Relationship With Him/Her *

His/Her Phone Number *

His/Her Address *

Line 1

Line 2

City

State

Zip Code

Country

How did you hear about So Big? / Who referred you to So Big? *

Baby's Information

THIS SECTION WILL BE FILLED OUT AFTER THE BIRTH OF YOUR BABY (ONLY FILL OUT IF YOU HAVE ALREADY GIVEN BIRTH TO THE BABY WHO WILL RESIDE AT MOUNTAIN HOUSE WITH YOU).

Baby's Name *

First

Last

Baby's Father's Name *

First

Last

Date of Baby's Birth *

Time of Baby's Birth *

Hospital of Baby's Birth *

City and State of Baby's Birth *

Baby's Social Security Number *

Baby's Height at Birth *

Baby's Weight at Birth *

Educational Information

Name of the High School You Attended *

School Address *

Line 1

Line 2

City

State

Zip Code

Country

School's Phone Number *

Have You Completed Your GED? *

Yes No

When and Where was your last test? *

Income Information

Do you have any source of income? This may include but may not be limited to employment earnings, child support payments, court settlement monies, social security, disability, TANF, gifts from family or friends. *

Yes No

If YES, how often do you receive payments? *

If YES, how much money do you receive? *

Medical Information

Physician Name *

First

Last

[object Object]

Physician Address *

Line 1

Line 2

City

State

Zip Code

Country

Physician Phone Number *

Please list any medications you are currently taking: *

Please list any medication you are allergic to: *

Have you ever been hospitalized? *

Yes No

For what reason? *

List all surgeries you have had and the dates performed: *

Do you have any physical ailments or disabilities that would inhibit normal physical activity? *

Yes No

If YES, explain: *

Do you wear glasses and/or contacts? *

Yes No Both

List all known allergies, other than to medications: *

Have you ever had a blood transfusion? *

Yes No

If Yes, when? *

Do you have special diet restrictions? *

Yes No

If YES, specify: *

Do you have any sexually transmitted diseases? *

Yes No

If Yes, please list: *

Have you been tested for HIV? *

Yes No

If yes, results: *

Positive Negative Inconclusive

Have you ever had or do you have any of the following conditions? Check all that apply. *

Severe or persistent headaches Blurred Vision Hearing Loss Hay Fever/Asthma Sinus Trouble Arthritis High Blood Pressure Low Blood Pressure Racing of the Heart Shortness of Breath Swelling in Ankles Rheumatic Fever Heart Trouble Blood in Urine Kidney Stones Stomach Ulcer Vomiting Blood Diarrhea Constipation Leg Cramps Severe Chest Pain Black Out Spells Backache Fatigue Dizziness Depression Anxiousness Seizures Diabetic

Past History:

Please check all that apply and list the age you were at that time in next section. *

Scarlet Fever Mumps Whooping Cough Measles Chicken Pox Smallpox Typhoid Fever Cancer Anemia Diphtheria Hepatitis (A,B, or C) AIDS/HIV Tuberculosis Pneumonia Epilepsy Depression Anxiety

List the age you were at the time you experienced any of the previous illnesses: *

Any other notes or comments on your medical history: *

Pregnancy Information

Have you had any previous miscarriages? *

Yes No

Number and Date(s): *

Have you had any abortions? *

Yes No

Number and Date(s): *

Have you placed any children for adoption? *

Yes No

Number and Date(s): *

Age of children at adoption: *

Is this your first full term pregnancy? *

Yes No

List any/all complications: *

Do you have any other children? *

Yes No

If you answered yes please complete these following questions. If no please skip down to the next section.

How many? *

Give names and ages: *

Do you have guardianship and/or custody of your child(ren)? *

Yes No

Are you currently parenting your child(ren)? *

Yes No

With whom is/are the child(ren) living? *

What is your relationship with that person? *

Pregnancy Info Continued

How was your current pregnancy confirmed? *

How many weeks are you? *

Approximate due date: *

Medical Coverage: *

Hoosier Healthwise? *

If other coverage, please specify *

Do you know who the father of your child is? *

Yes No

Your Unborn Baby’s Father's Name: *

First

Last

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Your Unborn Baby’s Father's Phone Number: *

His Current Age *

Rate your relationship with this individual at the time *

Really Good 10 9 8 7 6 5 4 3 2 Really Bad 1 No contact at all

Additional comments about your relationship: *

You Unborn Baby's Father's Race: *

White Black Hispanic Other

How does he feel about the pregnancy? *

Is your unborn baby’s father abusive? (call you names, threaten you, hit you, etc.) *

Yes No

Personal Information

Have you ever been arrested and/or convicted of any crime? *

Yes No

If YES, For what and give dates (please list all occurrences) *

Have you ever been in jail or prison? *

Yes No

If YES, For what and give dates AND COUNTY (please list all occurrences) *

Are you on probation? *

Yes No

If yes -- what county / state? *

Name of Probation Officer: *

First

Last

Probation Officer’s Telephone Number *

Do you have any court cases pending? *

Yes No

If yes, date(s): *

Pending Case: City and State *

Pending Case: Charge *

Do you smoke? *

Yes No

If yes, How many cigarettes/packs a day? *

Are you, or have you ever struggled with an addiction (drug, alcohol, sex, etc.)? *

Yes No

If Yes, what addiction(s) and give dates: *

Have you ever taken drugs? *

Yes No

If yes, What kind? *

Are you on any drugs now? *

Yes No

If yes, How long have you been on them? *

How long have you been clean? *

How often do you drink alcohol? *

What do you usually drink? *

How much do you drink? *

Heavy Moderate Light

Have you ever been through a “de-tox” program? *

Yes No

If yes, what program? *

Are you willing to be smoke, drug and alcohol free during your time at So Big Mountain House? *

Yes No

Are you willing to take random drug screens? *

Yes No

Relationship Information

Have you ever been in an abusive relationship with anyone? *

Yes No

If YES, who and give dates: *

If YES, are you still in this relationship? *

Yes No

If YES, are you fearful of this person? *

Yes No

If YES, does this person know your plans to live at So Big Mountain House? *

Yes No

Does your current boyfriend/partner/significant other/family member call you names, threaten you, hit you, or touch you inappropriately? *

Yes No

Please Explain *

Are you afraid of your boyfriend/partner/significant other/family member? *

Yes No

Are you afraid to leave your boyfriend/partner/significant other/family member? *

Yes No

Your Current Boyfriend/Partner/Significant Other:

Is your Current boyfriend/partner/significant other the father of your unborn baby? *

Yes No

Your Current Boyfriend/Partner/Significant Other Name *

First

Last

Your Current Boyfriend/Partner/Significant Other's Phone Number *

Your Current Boyfriend/Partner/Significant Other's Age *

Rate your relationship with this individual at the time: *

Really good 10 9 8 7 6 5 4 3 2 Really Bad 1 No contact at all

Additional comments about your relationship with this individual *

Your Family's Information

Family lifestyle: *

Single Parent Two Parents Two Parents/One Step-parent Homeless

Other Family Lifestyle *

Do your parent’s know that you are/were pregnant? *

Mother Father Neither

How Do You Parents Feel about it? (Please indicate both mother's and father's opinions) *

Do your parents know of your plans to be here? *

Yes No

If no, why? *

Your Father's Name *

First

Last

Your Father's Age *

Your Father's Cell Phone Number *

Your Father's Occupation *

Rate your relationship with this individual at the time: *

Really good 10 9 8 7 6 5 4 3 2 Really bad 1 No contact at all

Additional comments on your relationship with your father *

Your Mother's Name *

First

Last

Your Mother's Age *

Your Mother's Cell Phone Number *

Your Mother's Occupation *

Rate your relationship with this individual at the time: *

Really good 10 9 8 7 6 5 4 3 2 Really bad 1 No contact at all

Additional comments on your relationship with your mother *

FILL OUT THIS SECTION ONLY IF YOU LIVE WITH SOMEONE OTHER THAN YOUR PARENTS.

Please choose the one that applies to your family situation: *

Step-Mother Step-Father

Other family situation *

His/Her Name *

First

Last

His/Her Phone Number *

His/Her Age *

His/Her Occupation *

Rate your relationship with this individual at the time: *

Really good 10 9 8 7 6 5 4 3 2 Really bad 1 No contact at all

Additional comments about your relationship with this person *

FILL OUT THIS SECTION ONLY IF THERE IS SOMEONE ELSE WHO HAS AN IMPORTANT ROLE IN YOUR LIFE.

Name *

First

Last

Relationship to you *

Their Phone Number *

Rate your relationship with this individual at the time: *

Really good 10 9 8 7 6 5 4 3 2 Really bad 1 No contact at all

Additional comments about your relationship with this person *

Thank you for taking the time to fill this application out. Please click the button below to submit your application.

Submit

So Big is a registered 501(c)(3) organization as recommended by the United States IRS. Any gift made to So Big qualifies as a tax-deductible charitable contribution, and you will be receipted.

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I Need Help
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