Application - Compassion House

Compassion House is a faith-based teen residential program for mothers ages 11 through 17 who are pregnant or have recently given birth within the last year. In addition to classes and helping to meet a mother's practical needs such as diapers, clothing etc., Some of the most therapeutic moments occur when cooking meals, enjoying dinner as a family, changing diapers, playing with babies, or playing games. Our amazing team works with each mother to provide an individualized growth program (IGP) that incorporates the mother's goals during her stay for education, career, and life objectives for herself and her child. We will help her meet those goals while providing her and her child with a private bedroom, a safe and nurturing environment, and educational opportunities.

At Compassion House you will receive all the help you and your baby need.

We offer a safe home and food and ensure you receive the proper prenatal care. Whether you choose to parent or are considering adoption, we offer a structured, secure, Christ-centered environment where you can learn and become a confident, independent woman. Our full-time staff, 24/7 on-site house moms, and fellow residents can help you understand you are not alone. Whatever your situation, Compassion House is here to help.

Compassion House firmly believes in allowing you to choose between parenting and adoption. We believe that while you are here working on plans for your future, God will give you the answers and lead you in the direction He has mapped out for your life and child.

Additionally, our young mothers receive access to:

Educational and classes support
Specialized classes
Education
Individual Counseling
Group Counseling
Parenting Classes
Recreational outings
Mentoring
Labor Coach
Aftercare Services

Application Guidelines

Because Compassion House serves youth who are working towards greater independence and responsibility, the application process is designed to move youth in that direction. This process helps determine the youth's commitment, motivation, and need for the program.

Admission Requirements

Pregnant or parenting teens 11-17.
Must not be under the jurisdiction of any foster care system.
If under treatment by a psychiatrist or on medication at the time of inquiry, must be stable and actively engaged and remain in treatment during residency.
Drug, tobacco, and alcohol-free.
Able to prove if the applicant has a history of substance abuse, has a minimum of 30 days of documented sobriety, and is willing to participate in a celebrated recovery program.

Resident Expectations

Participate in group and individual counseling.
Have or will be willing to work towards a high school diploma or GED.
Ability and willingness to be employed part-time after giving birth.
Willingness to live in a community setting for 6 to 18 months with a least a six months postpartum stay.
Agree to attend and participate in all workshops and classes in and outside of Compassion House.
Willingness and ability to follow program structure.
Agrees to case management services.
Agrees to read and follow all resident and household guidelines.Complete daily chores and other assigned tasks.
Complete a 7 and 30 day probation.
Follow all policies and procedures.
Adhere to curfew and outings policy.
Treat all staff, residents, volunteers, etc., with dignity and respect.
Protect the privacy of other residents.
Compassion House does not tolerate threatening or violent behavior; this includes but is not limited to physical violence, emotional abuse, bullying, cyberbullying, or any other hateful conduct.

The First Step is to fill out the pre-screening application below.

After receiving a prospective resident's completed application, we will call you to explain the program in more detail. Before acceptance, to determine eligibility and compatibility for the program, we will schedule a time to meet with you in person or over Zoom.

There is no charge to live at Compassion House, but we do require a desire to learn, accept help, coaching, and support.

Are you ready to make a change and accept help?

General Information

Name *

First

Last

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Email *

Phone *

Mailing Address *

Address Line 1

City

State

Zip Code

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Date of Birth *

Birthplace City and State * *

Age

Are you a US citizen? *

Yes
No

Why do you want to become a resident at Compassion House? *

Other than pregnancy and parenting what are three goals you want to work towards while at Compassion House? (copy) *

What are some of your hobbies and interests? *

What is your current living situation?

If other, please explain:

Ethnicity (Check all that apply)

If other, please explain:

Emergency Contact

Name *

First

Last

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Phone *

Relationship to Applicant *

Identification

Do you have your:

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If parenting does your child have a

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If you do not have one or more of the above documents would there be any issues in obtaining them before admitted? If yes please explain

I understand I must have all of the above documents before I can be accepted into the Compassion House Program

Yes
No

Education

Do you have a high school diploma or GED?

Yes
No

If yes date of graduation

Are you currently enrolled in high school or a GED program

Yes
No

Name and address of last school attended

Phone Number of last school attended

Highest grade completed

How do you intend on obtaining diploma?

If you have not graduated and are not currently enrolled in school what is your reason for leaving?

Are you or have you ever been enrolled in special education classes?

Yes
No

Do you have any identified educational related problems? (ADD/ADHD/Behavioral/Learning disabilities/Reading Comprehension?

Yes
No

Are you on or have you ever had an IEP or 504

Yes
No

Medical

Are you pregnant? *

Yes
No

Is your pregnancy confirmed? *

Yes
No

How was your pregnancy confirmed *

Doctor
Nurse
Clinic
Home Test

What is the first day of your last period? *

What is your due date?

How many pregnancies have you had

How many resulted in a live birth

How many resulted in a stillbirth

How many resulted in a miscarriage

How many were ended by abortion

Do you have any children not in your custody or care?

Yes
No

If Yes, Please Explain.

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Height *

Weight before Pregnancy *

Current weight *

Do you have any allergies? *

Yes
No

Please list all your allergies *

Are you taking any medication or dietary supplements? *

Yes
No

If yes please list *

Do you have any current physical health problems? *

Yes
No

If yes please explain *

Do you have any special needs that we should be aware of? *

Yes
No

If yes please explain *

Do you have any physical limitations and or medical conditions as indicated by a physician? *

Yes
No

If yes please explain *

Have you had any past surgeries or medical hospitalizations? *

Yes
No

If yes please explain *

Have you ever received inpatient mental health services? *

Yes
No

If yes please explain the circumstances *

Facility name(s) you received inpatient mental health services *

Was a safety plan put in place? *

Yes
No

What was/is your safety plan? *

Are you still following your safety plan? *

Yes
No

Are you or have you ever been under the care of a psychologist or psychiatrist? *

Yes
No

Are you currently seeing a counselor or therapist? *

Yes
No

If No, Have you seen a counselor or therapist in the last two years? *

Yes
No

Name of last counselor/therapist seen *

Phone number of your counselor/therapist

Have you ever been diagnosed or treated for any of the following? *

Substance Use

Check any substances with which you have experimented. *

If other, please explain

Drug of choice

Length of use

Date last used

Have you ever received inpatient treatment for a drug or alcohol abuse *

Yes
No

If yes What was the facility name and dates admitted

I understand during the admission process I will have to give a urine sample.

Nutrition

Do you have any dietary restrictions/ Limitations? *

Yes
No

Do you currently struggle with any issues related to food or eating? *

Yes
No

Have you ever struggled with issues related to food or eating? *

Yes
No

Do you currently eat meat? *

Yes
No

Have you been diagnosed or treated by a physician for an eating disorder? *

Yes
No

Financial

Compassion House is not financially responsible for any resident under its care. Any bills received will be the responsibility of the residents guardian.

Do you currently have health insurance coverage? *

Yes
No

Do you currently receive any government assistance. If yes please provide assistance received *

Do you currently receive any income that is not from employment. If yes please provide the source of income and the amount

Do you currently have a bank account

No
Checking
Savings
Both Checking and Savings

Legal Background

Have you ever been arrested? *

Yes
No

Have you ever been charged with a crime? *

Yes
No

Have you ever been convicted of a crime? *

Yes
No

Do you have any outstanding warrants? *

Yes
No

Do you have any pending court dates? *

Yes
No

Are you currently incarcerated? *

Yes
No

Are you currently on probation? *

Yes
No

Are you currently on parole? *

Yes
No

Name and Phone Number of Probation / Parole Officer

Name and Phone Number of public defender / attorney

Name and Phone Number of Judge / County

Personal History

(Please answer honestly)

Have you ever tried to commit suicide? *

Yes
No

Have you ever self-harmed? *

Yes
No

Have you ever been the victim of sexual abuse? *

Yes
No

Have you ever been the victim of physical abuse? *

Yes
No

Have you ever been the victim of neglect? *

Yes
No

Have you ever been involved in prostitution? *

Yes
No

Are you currently involved in any occult activities? (Including been limited to fortune telling, palm rating, tarot cards, Ouija Board, witchcraft Etc.) *

Yes
No

Family History

Legal Guardians Name. Relationship to applicant *

Mother's Name *

Father's Name *

Is your Mother *

Living
Deceased
Unknown

Is your Father *

Living
Deceased
Unknown

Do you have any brothers? If yes, how many? *

Do you have any sisters? If yes, how many? *

What is your current marital status? *

Married
Divorced
Separated
Single / never married

Spiritual History

Have you ever committed your life to God? *

Yes
No

What denomination/church are you affiliated with?

How active were your parents in their faith and beliefs?

How often do you attend church?

Do you feel you have a need for God …. Explain?

What is your present relationship with God?

Placement

Name of placing parent/ Legal Guardian/ or agency *

Address *

Address Line 1

City

State

Zip Code

Layout

Phone *

Email *

Are there any other individuals who have legal authority over the minor? If yes who?

How did you learn of Compassion House? Referred by?

Has either parent had the parental rights terminated by the court?

Why are you requesting admission into Compassion House?

What does the teen believe is the reason for their placement into Compassion House?

Does the teen exhibit any high risk behaviors including running away? If yes please explain

Other than pregnancy and parenting what are three goals you want the teen to work towards while at Compassion House?

Compassion House Resident Placement Application

At Compassion House you will receive all the help you and your baby need.

Application Guidelines

Admission Requirements

Resident Expectations

The First Step is to fill out the pre-screening application below.

Are you ready to make a change and accept help?

General Information

Emergency Contact

Identification

Do you have your:

If parenting does your child have a

Education

Medical

Substance Use

Nutrition

Financial

Legal Background

Personal History

Family History

Spiritual History

Placement

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Address

Connect

P: 479.419.9100

e: compassionhouse.ar@gmail.com