Apply for Admission / The Residential Home / About | A Place for Us Ministries International

Name *

Email address *

Phone Number *

Age *

Are you pregnant? *

Yes
No
Unknown/not sure

If yes, what is your due date? *

Is the birth father involved? *

Yes
No

What are your parenting plans? *

Parent my child (single-mother)
Parent my child (with birth father)
Parent my child (with parental assistance)
Adoption
Family Relative

Do you have a history of substance use? If yes, please check your preferred substance(s). *

Yes
No
Marijuana
Opiods
Meth
Alcohol
Heroin
Other

Have you completed a recovery or treatment program? *

Yes
No

If yes, please provide the name of the facility, contact person, phone number or email: *

Other agencies involved: *

DSS open case
DJJ or Probation Officer
Medicaid secured
WIC vouchers secured
Food Stamps secured

Do you have other children? *

Yes
No

Give a brief statement about why you would like to come to A Place for Us Ministries: *

Do you have a willing heart to seek change? *

Yes
No
Not sure