A Place for Us Ministries International
A Place for Us Ministries International
Home
About
The Residential Home
Apply for Admission
The Alcoves
Gather Bistro & Bakery
Salon Beautopia
Nicaragua Mission
Our Farm
Support Us
Ways to Give
Ways to Serve
Contact
Job Postings
Apply for Admission
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
Leave this field empty
Submit form