INITIAL INQUIRY SCREENINGFull Name *Preferred Name *Date of Birth *Phone Number *Email Address *City *State/Province *Contact & SafetyIs this a safe phone number to call/text? *YesNoIs it okay to leave a voicemail? *YesNoIs this a safe email to contact you? *YesNoEmergency contact (Name, Relationship, Phone) *Are there any immediate concerns we should be aware of? (optional)Pregnancy InformationAre you currently pregnant? *YesNoIf yes, what is your due date? *How many weeks pregnant are you? *Are you considered a high risk pregnancy?Have you confirmed your pregnancy by a medical professional (i.e. doctor, pregnancy resource center, etc.)?Have you had any medical care to date?Do you have an OB doctor?Household InformationDo you have any children? *YesNoIf yes, how many children do you have?Please list each child’s age:Will your child (ren) have a safe place to live while in our program?Yes, allSomeNoIf some or none, please briefly explainDo you currently have legal custody of your child(ren)?YesNoCurrent Situation & NeedsWhat is your current living situation? *What is prompting you to seek support at this time?What are your most immediate needs (check all that apply) *HousingFoodTransportationEmploymentCounseling/Emotional SupportOtherDo you currently have a support system? (church, family, friends)YesNoProgram Interest & FitWhy are you interested in In My Shoes?Are you willing to participate in a structured program with guidelines (curfew, chores, classes, etc.) *YesNoHave you ever lived in a residential or supportive program before?YesNoIf yes, where and when?Spiritual ComponentIn My Shoes is a faith-based program. Are you open to participating in spiritual activities?In My Shoes is a faith-based program. Are you open to participating in spiritual activities?YesNoWould you like spiritual support during your time in the program?YesNoHealth & WellbeingAre there any medical conditions we should be aware of? *Are you currently receiving mental health support? *YesNoAre you currently taking any medications we should be aware of? *Please list your medications in the space provided.LegalDo you have any upcoming court dates or legal obligations? *YesNoDo you have reliable transportation? *YesNoAre you currently employed or in school? *YesNoDo you have a current source of income? *YesNoIf yes, please explainI understand that completing this form does not guarantee acceptance into the program. *YesI certify that the information provided is true and accurate to the best of my knowledge. *Start signing your signature hereYour browser does not support e-Signature field.I give consent for In My Shoes staff to contact me regarding my application. *YesThank you for completing this form. A member of our team will review your information and contact you within 3 business days to discuss next steps. SubmitPlease do not fill in this field.
