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Aunt Mary's House Guest Application

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Aunt Mary’s House – Guest Application
P.O. Box 955, Norwich, NY 13815

For your privacy, please do not include your Social Security number anywhere on this form. Our staff will collect it from you in person.

Personal Information

Today’s Date *

Referred By

Full Name *

Date of Birth *

Contact Phone Number *

Email Address *

Last Address

Street

City

State

Zip

Marital StatusSingleMarriedDivorcedWidowed

Are you homeless?YesNo

Are you at risk of being homeless?YesNo

Briefly describe your current living situation

How soon do you want to come to Aunt Mary’s House?

Do you have medical insurance?YesNo

Insurance provider

Have you applied for Food Stamps?YesNo

WIC?YesNo

TANF?YesNo

Do you have other means of support?YesNo

Whom/What?

DSS Caseworker’s Name

DSS Caseworker Phone

Child(ren)’s Information

Child 1

Name

Age

Birthdate

Pediatrician

Immunizations Current?YesNo

Child 2

Name

Age

Birthdate

Pediatrician

Immunizations Current?YesNo

Child 3

Name

Age

Birthdate

Pediatrician

Immunizations Current?YesNo

Child 4

Name

Age

Birthdate

Pediatrician

Immunizations Current?YesNo

Pregnancy Information

Has a pregnancy test been done?YesNo

When?

Have you been seen by a doctor?YesNo

Doctor’s name

What is your Due Date?

Last Menstrual Cycle?

Have you ever been pregnant before?YesNo

How many times?

How many live births have you had?

What changes will this pregnancy make in your life?

Explain how your family responded to you when you shared with them your situation regarding your pregnancy

Is the father of your child still involved in your life?

What would you change about the relationship you have with your child’s father?

Is the father of your child still involved in your child’s life?

How do you feel about the relationship your child(ren) have with their father?

Have you considered adoption?YesNo

Would you like adoption counseling?YesNo

Emergency Contact Information

Emergency Contact 1

Name *

Phone *

Address

City

State

Zip

Emergency Contact 2

Name

Phone

Address

City

State

Zip

Family Members and/or Persons Significant to the Child(ren)

Person 1

Name

Age

Relationship

Person 2

Name

Age

Relationship

Person 3

Name

Age

Relationship

Person 4

Name

Age

Relationship

Education Information

Are you currently in school?YesNo

Current or previous school name

Do you plan on getting your Diploma?YesNo

GED?YesNo

Do you have your High School Diploma?YesNo

GED?YesNo

Completion date?

Medical Health History

Please list current medications

Please list allergies to food or medications

Have you ever had any of the following? (check all that apply)Liver DiseaseKidney/Bladder ProblemsAsthmaSleep DifficultyMenstrual ProblemsHeadachesDiabetesHepatitisConstipationTuberculosisEpilepsy/SeizuresDizzinessHigh Blood PressureCancerUlcersHeart ProblemsStomach PainLoss of AppetiteSexually Transmitted DiseaseEating DisorderOther

If Other, please explain

Do you have any other current or past medical problems?YesNo

If yes, what?

Have you ever smoked?YesNo

Are you still smoking?YesNo

If so, how many cigarettes?

Have you ever consumed alcohol or used street drugs?YesNo

Date of last use

Have you consumed alcohol or used street drugs since you found out you are pregnant?YesNo

If yes, what have you used?

Date of last use

Mental Health

Have you ever been in counseling?YesNo

If yes, please complete:

Counseling 1

Dates

Name of Counseling Center or Counselor

Reason

Counseling 2

Dates

Name of Counseling Center or Counselor

Reason

Counseling 3

Dates

Name of Counseling Center or Counselor

Reason

Counseling 4

Dates

Name of Counseling Center or Counselor

Reason

Do you have a history of any of the following? (check all that apply)DepressionSuicide Attempt(s)AnxietySchool ProblemsFamily ConflictsSelf-HarmRunning AwayEating DisorderDrug and/or Alcohol ProblemsPhysical, Sexual or Emotional Abuse

Employment History

Employer 1

Employer Name

Address

Supervisor’s Name

Phone/Email

Start Date

End Date

Employer 2

Employer Name

Address

Supervisor’s Name

Phone/Email

Start Date

End Date

Employer 3

Employer Name

Address

Supervisor’s Name

Phone/Email

Start Date

End Date

Residential History

Please provide your last 5 residences/addresses.

Residence 1

Landlord Name

Landlord Phone/Email

Address of residence

Start Date

End Date

What was the reason for leaving?

Residence 2

Landlord Name

Landlord Phone/Email

Address of residence

Start Date

End Date

What was the reason for leaving?

Residence 3

Landlord Name

Landlord Phone/Email

Address of residence

Start Date

End Date

What was the reason for leaving?

Residence 4

Landlord Name

Landlord Phone/Email

Address of residence

Start Date

End Date

What was the reason for leaving?

Residence 5

Landlord Name

Landlord Phone/Email

Address of residence

Start Date

End Date

What was the reason for leaving?

Legal Information

Have you had any arrests?YesNo

Are you on probation/parole?YesNo

Name of PO

How often do you report?

Do you owe restitution?YesNo

Mandatory drug testing?YesNo

If yes to any of the above questions, please explain

List 3 Goals You Would Like to Accomplish While at Aunt Mary’s House

1.

2.

3.

List 3 Strengths You Possess

1.

2.

3.

List 3 of Your Weaknesses

1.

2.

3.

Additional Information

Do you have anything else you would like us to know?

Signature

I have filled out this application to the best of my ability.

Signed (type your full name) *

Date *

Aunt Mary's House

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