Client Survey

Section A: Prenatal Mom

Information about the pregnant mom who is applying.

Applying Pregnant woman Name:*

First Middle Initial Last

Date Of Birth:*

MM

DD

YYYY

Ethnicity: Is the Applying Pregnant Woman Hispanic or Latino Origin?*

Yes
No

Race:*

Health Insurance:*

Medicaid
Private
Military Health
No Health Insurance

Insurance Provider:*

HMSA
Kaiser
Aloha Care

Insurance Provider:*

Tri-Care

Policy/Medical Record Number:*

Does you have a secondary insurance?*

Yes
No

Secondary Health Insurance:*

Medicaid
Private
Military Health

Secondary Insurance Provider:*

HMSA
Kaiser
Aloha Care

Secondary Insurance Provider:*

Tri-Care

Second Policy/Medical Record Number:*

Pregnant Woman Type*

18 years old or older
Under 18 years old

Expected Delivery Date:*

MM

DD

YYYY

Home Phone Number:

Cell Phone Number:*

Text Message

Yes
No

Email

Highest grade completed in school:*

Employment Status: (Check all that apply)*

Full time Work (35+hrs/wk or more)
Part Time Work (Under 35 hrs/wk)
Unemployed
Training or in School
Self-Employed
Seasonally Employed
Retired or Disabled
Stay at Home Parent

Military Status:*

Active
Veteran
N/A

Section B: Family Information

Living Address:*

Street Address Address Line 2 City State ZIP Code

Is your Mailing Address the same as living Address?*

Yes
No

Mailing Address:*

Street Address Address Line 2 City State ZIP Code

Parental Status:*

Two Parents
One Parent

Are you Currently Homeless?

Housing:*

Own
Rent
Public Housing (Section 8, Subsidized, etc.)
Live with relative/friend

Please check all services your family currently receives:*

None
TANF
Food Stamp/SNAP
WIC
Supplemental Security Income (SSI)
Other

Primary Language:*

Secondary Language:

Section C: Primary Adult

Information about the primary adult responsible for the applying pregnant mom.

Adult 1 Name:

First Middle Initial Last

Adult 1 Date of Birth:

MM

DD

YYYY

Adult 1 Gender:

Male
Female

Adult 1 Ethnicity: Are you Hispanic or Latino Origin?

Yes
No

Adult 1 Race:

Adult 1 Home Phone Number:

Adult 1 Cell Phone Number:

Adult 1 Text Message

Yes
No

Adult 1 Email Address:

Adult 1 Relationship to pregnant mom:

Adult 1 Does the pregnant mom live with you?

Yes
No
Part Time

Adult 1 Do you have the same home and mailing address as the pregnant mom?

Yes
No

Adult 1 If No please provide current address:

Street Address Address Line 2 City State ZIP Code

Adult 1 highest grade completed in school:

Adult 1 Employment Status: (Check all that apply)

Full time Work (35+hrs/wk or more)
Part Time Work (Under 35 hrs/wk)
Unemployed
Training or in School
Self-Employed
Seasonally Employed
Retired or Disabled
Stay at Home Parent

Adult 1 Military Status:

Active
Veteran
N/A

Section D: Secondary Adult

Information about the secondary adult responsible for applying pregnant mom.

Adult 2 Name:

First Middle Initial Last

Adult 2 Date of Birth:

MM

DD

YYYY

Adult 2 Gender:

Male
Female

Adult 2 Ethnicity: Are you Hispanic or Latino Origin?

Yes
No

Adult 2 Race:

Adult 2 Home Phone Number:

Adult 2 Cell Phone Number:

Adult 2 Text Message

Yes
No

Adult 2 Email Address:

Adult 2 Relationship to pregnant mom:

Adult 2 Does the pregnant mom live with you?

Yes
No
Part Time

Adult 2 Do you have the same home and mailing address as the pregnant mom?

Yes
No

Adult 2 If No please provide current address:

Street Address Address Line 2 City State ZIP Code

Adult 2 highest grade completed in school:

Adult 2 Employment Status: (Check all that apply)

Full time Work (35+hrs/wk or more)
Part Time Work (Under 35 hrs/wk)
Unemployed
Training or in School
Seasonally Employed
Self-Employed
Retired or Disabled
Stay at Home Parent

Adult 2 Military Status:

Active
Veteran
N/A

Section E: Other Family Members Supported by Your or Guardian's Income

Estimated Annual Income:*

Number of adults in your family:*

(Use numbers)

Other Adult 1 Name:

First Middle Initial Last

Other Adult 1 Relationship to Applying Pregnant Mom

Other Adult 1 Date of Birth

MM

DD

YYYY

Other Adult 1 Gender:

Male
Female

Other Adult 2 Name:

First Middle Initial Last

Other Adult 2 Relationship to Applying Pregnant Mom

Other Adult 2 Date of Birth

MM

DD

YYYY

Other Adult 2 Gender:

Male
Female

Other Adult 3 Name:

First Middle Initial Last

Other Adult 3 Relationship to Applying Pregnant Mom

Other Adult 3 Date of Birth

MM

DD

YYYY

Other Adult 3 Gender:

Male
Female

Other Adult 1 Name:

First Middle Initial Last

Other Adult 1 Relationship to Applying Pregnant Mom

Other Adult 1 Date of Birth

MM

DD

YYYY

Other Adult 1 Gender:

Male
Female

Other Adult 2 Name:

First Middle Initial Last

Other Adult 2 Relationship to Applying Pregnant Mom

Other Adult 2 Date of Birth

MM

DD

YYYY

Other Adult 2 Gender:

Male
Female

Other Adult 1 Name:

First Middle Initial Last

Other Adult 1 Relationship to Applying Pregnant Mom

Other Adult 1 Date of Birth

MM

DD

YYYY

Other Adult 1 Gender:

Male
Female

Other Adult 2 Name:

First Middle Initial Last

Other Adult 2 Relationship to Applying Pregnant Mom

Other Adult 2 Date of Birth

MM

DD

YYYY

Other Adult 2 Gender:

Male
Female

Other Adult 3 Name:

First Middle Initial Last

Other Adult 3 Relationship to Applying Pregnant Mom

Other Adult 3 Date of Birth

MM

DD

YYYY

Other Adult 3 Gender:

Male
Female

Number of children in your family:*

(Use numbers)

Other Child 1 Name:

First Middle Initial Last

Other Child 1 Relationship to Applying pregnant mom:

Other Child 1 Date of Birth:

MM

DD

YYYY

Other Child 1 Gender:

Male
Female

Other Child 2 Name:

First Middle Initial Last

Other Child 2 Relationship to Applying pregnant mom:

Other Child 2 Date of Birth:

MM

DD

YYYY

Other Child 2 Gender:

Male
Female

Other Child 3 Name:

First Middle Initial Last

Other Child 3 Relationship to Applying pregnant mom:

Other Child 3 Date of Birth:

MM

DD

YYYY

Other Child 3 Gender:

Male
Female

Other Child 4 Name:

First Middle Initial Last

Other Child 4 Relationship to Applying pregnant mom:

Other Child 4 Date of Birth:

MM

DD

YYYY

Other Child 4 Gender:

Male
Female

Other Child 5 Name:

First Middle Initial Last

Other Child 5 Relationship to Applying pregnant mom:

Other Child 5 Date of Birth:

MM

DD

YYYY

Other Child 5 Gender:

Male
Female

Other Child 6 Name:

First Middle Initial Last

Other Child 6 Relationship to Applying pregnant mom:

Other Child 6 Date of Birth:

MM

DD

YYYY

Other Child 6 Gender:

Male
Female

Other Child 7 Name:

First Middle Initial Last

Other Child 7 Relationship to Applying pregnant mom:

Other Child 7 Date of Birth:

MM

DD

YYYY

Other Child 7 Gender:

Male
Female

Other Child 8 Name:

First Middle Initial Last

Other Child 8 Relationship to Applying pregnant mom:

Other Child 8 Date of Birth:

MM

DD

YYYY

Other Child 8 Gender:

Male
Female

Other Child 9 Name:

First Middle Initial Last

Other Child 9 Relationship to Applying pregnant mom:

Other Child 9 Date of Birth:

MM

DD

YYYY

Other Child 9 Gender:

Male
Female

Section F

How did you hear about us?*

Referring Agency: (Specify)

Contact:

Phone #:

DOE Referring Agency: (Specify)

Contact:

Phone #:

Early Intervention Referring Agency: (Specify)

Contact:

Phone #:

CERTIFICATION: Please Read and Submit Your Application

Nondiscrimination Statement*

I certify that the information provided herein, and in any other related documents and/or representations, are true and correct to the best of my knowledge, and I understand that access to any and all HCAP premises, programs and/or services through misrepresentation or fraud may be punishable under HCAP policies, procedures, or practices including, but not limited to, refusal of services, at the sole discretion of HCAP. I further understand that a false statement under these forms or other communications can also expose me to civil and/or criminal liability that may include financial obligations or criminal penalties. I understand that this information will be used only to determine if I may gain entry onto any and all HCAP premises, and/or to determine if I and my family are eligible for any and all HCAP services, and will not be released to non-HCAP sources without my prior knowledge and written consent. HCAP does not discriminate on the basis of race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age (40 or older), disability and genetic information (including family medical history), or reprisal or retaliation for prior civil rights activity in any program or activity conducted.

Yes, I agree to Terms and Conditions
No, I do not agree to Terms and Conditions

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Section A: Child Applicant

Section B: Family Information

Section C: Primary Adult

Section D: Secondary Adult

Section E: Other Family Members Supported by Guardian's Income

Section F

Certification: Please Read and Submit Your Application

Pregnant Woman Application - 2023

Section A: Prenatal Mom

Section B: Family Information

Section C: Primary Adult

Section D: Secondary Adult

Section E: Other Family Members Supported by Your or Guardian's Income

Section F

CERTIFICATION: Please Read and Submit Your Application