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

    Need Help Filling Out This Form? Click to Email Us.

    Is The Elizabeth House Right for Me?

    Are you pregnant?
    The Elizabeth House is for women who are pregnant or who have an infant.
    Do you have children over the age of two?
    The Elizabeth House is not able to accommodate children over the age of two. If your older children are in your care, please contact us for a referral to another agency.
    Do you have alcohol or drug concerns?
    Before becoming a resident of The Elizabeth House, you must pass a urine drug test.
    Do you have a criminal background?
    The Elizabeth House provides a safe environment for our residents. To provide a safe environment, we are not able to accept women who have a violent criminal history.
    Do you have a diagnosed mental health condition?
    The Elizabeth House is not equipped to care for women who have been clinically diagnosed by their doctor with schizophrenia, severe bi-polar or severe behavior disorders.
    Are you ready to make a change in your life?
    We specialize in giving pregnant women a safe, nurturing place to make a new start, but you have to have a strong desire to make life changes and be willing to accept help to make those changes. Complete the screening form today to get started.

    The Elizabeth House is a program of Care Net Pregnancy Center of Dane County.
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