The Elizabeth House Pre-Screening Application

You made the first step – exploring your options is always a good thing! The Elizabeth House offers safe and stable housing to pregnant single women, ages of 18+. We accept applications from pregnant women, women who have recently given birth, and expectant mothers with a child up to the age of two.
Residents must be willing to learn new skills and must be committed to cooperating and participating in the program requirements and responsibilities.

    Interested in becoming part of The Elizabeth House? Take the first step by completing this form. We will respond to you within 2 to 3 business days.

    Your first name:

    Your last name:

    Your phone:

    Your email:

    Your preferred communications method: TextEmailCall

    Is it OK to identify ourselves as The Elizabeth House in communications (required): YesNo

    Your date of birth:

    Are you pregnant? YesNo

    Your due date:

    Are you currently receiving prenatal care? (Prenatal care includes visits to a doctor, nurse, OBGYN, or other health care worker before your baby is born to get checkups and advice about pregnancy) YesNo

    If you are not pregnant or if you have additional children in your custody, please list their birth dates below:
    Child 1:
    Child 2:
    Child 3:

    Do you have any children NOT in your custody or care? YesNo

    What is your racial/ethnic group? Black/African AmericanCaucasian/WhiteHispanic/LatinaBi/Multi-RacialAsianHawaiian/Pacific IslanderAmerican IndianOther

    What is your marital status?Never marriedMarriedWidowedDivorcedSeparated

    Do you have a valid driver's license? YesNo

    Do you own a car? YesNo

    How do you usually get places you need to be like work or the grocery store? (select all that apply) My own vehicleBorrow a vehicle from family/friendGet a ride from family/friendBusTaxicab, Uber, or LyftWalkingOther

    Describe your current housing situation: Living with family/friendEmergency shelterTransitional HousingDomestic violence shelterResidential substance abuse facilityHotelLiving on the street or in carRent or own apartment/houseOther

    Why is your current housing situation not working out? (select all that apply) Domestic violence, interpersonal or relational violenceMy own substance abuse issuesPressure for abortionMy own mental health issuesLoss of employment/incomeAged out of foster careRecent loss of housingChronic homelessnessUnsafe neighborhoodCannot stay once the baby is bornOther

    The Elizabeth House is a program of Care Net Pregnancy Center of Dane County.
    Copyright Care Net Pregnancy Center of Dane County | All rights reserved
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