Mountain House Application - So Big

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

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

* Indicates required field

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 *

Name of the Guidance Counselor *

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

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

Past History:

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

Amount and Date(s): *

Have you had any abortions? *

Yes No

Amount and Date(s): *

Have you placed any children for adoption? *

Yes No

Amount 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

Your Unborn Baby’s Father's Address: *

Line 1

Line 2

City

State

Zip Code

Country

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

Your Unborn Baby’s Father's Date of Birth *

His Current Age *

Your Unborn Baby’s Father's Social Security Number *

Your Unborn Baby's Father's Occupation and Place of Work *

His Work Phone Number *

His Education: *

His Emergency Telephone Number: *

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 Address *

Line 1

Line 2

City

State

Zip Code

Country

Your Current Boyfriend/Partner/Significant Other Phone Number *

Your Current Boyfriend/Partner/Significant Other's Date of Birth *

Your Current Boyfriend/Partner/Significant Other's Social Security Number *

Your Current Boyfriend/Partner/Significant Other's Occupation and Place of Work *

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

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

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

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) *

If you are over 18, do your parents know of your plans to be here? *

Yes No

If no, why? *

Your Father's Name *

First

Last

Your Father's Date of Birth *

Your Father's Address *

Line 1

Line 2

City

State

Zip Code

Country

Your Father's Home Phone Number *

Your Father's Cell Phone Number *

Your Father's Social Security Number *

Your Father's Occupation and Place of Work *

Your Father's Work Phone Number *

Your Father's Education *

Your Father's Emergency Phone Number *

Additional comments on your relationship with your father *

Your Mother's Name *

First

Last

Your Mother's Date of Birth *

Your Mother's Address *

Line 1

Line 2

City

State

Zip Code

Country

Your Mother's Home Phone Number *

Your Mother's Cell Phone Number *

Your Mother's Social Security Number *

Your Mother's Occupation and Place of Work *

Your Mother's Work Phone Number *

Your Mother's Education *

Your Mother's Emergency Phone Number *

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 Address *

Line 1

Line 2

City

State

Zip Code

Country

His/Her Phone Number *

His/Her Date of Birth *

His/Her Social Security Number *

His/Her Occupation and Place of Work *

His/Her Education *

His/Her emergency Phone Number *

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 Address *

Line 1

Line 2

City

State

Zip Code

Country

Their Phone Number *

Their social security number *

Their Occupation and Place of Work *

Their Work Phone Number *

Their education *

Their emergency Phone Number *

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.

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