Maternity Home

Maternity Home

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If you are interested in getting help from Lois' Lodge, please fill in the application and click the submit button. All information is kept in strictest confidence. If you prefer, you can print out this form and mail in to us at Lois' Lodge, 1316 Hemlock Street, Charlotte, NC 28203. Please provide us with detailed information as to how you would like to be contacted. If you prefer to contact us rather than having us call you, please phone Debbie at 704-376-8550 immediately upon submitting your application so that we can arrange to meet with you.

Name *
E-mail Address *
Full Name *
Date of Birth: *
SS Number:
Age: *
Race:
Phone number where you wish to be contacted at this time: *
Current Address: *
City *
State: *
Zip Code: *
Referred by: *
Marital Status: *
Estimated Delivery Date: *
Do you have children in your care? *	Yes No
Why do you need to live in a maternity home during your pregnancy? *
How is your family involved in your situation (financially, emotionally,etc.)? *
To what extent is the father of your baby involved in your situation? *
Name of the last school that you attended? *
Date last attended:
Grade level:
Do you presently have a job? If so, where? What job experience do you have? *
How do you support yourself financially?
Have you ever been convicted of a crime, other than a traffic violation? *	Yes No
If yes, please explain:
Who should we contact in case of an emergency? Please provide name, address and phone number.
If the contact given above is not a parent, please provide your parents' names and addresses:
If you are currently receiving medical care, please list the names and addresses of your physicians and the type of treatment you are receiving from each: *
Are you currently working with the County Department of Social Services or a private agency to assist you with planning and decision-making for your baby? If so, please provide name of agency. *
Have you been abused in the past? *	Yes No
If yes, by whom? What was the nature of the abuse?
Do you currently or have you in the past used drugs and/or alcohol? *	Yes No
If yes, please explain:
Have you ever received psychological counseling? *	Yes No
If yes, please explain:
	Please check to certify that all information you have provided is true to the best of your knowledge.
	Check box to reflect that you understand that Lois' Lodge may secure a background check as a part of the application process.
	Check box if you are applying for consideration for the Lois' Lodge maternity home program.

* Fields marked with an asterisk are required fields

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You can join in the work of Lois' Lodge through a one time gift
or by providing ongoing monthly support.: http://www.loislodge.org/donate.html

Lois' Lodge * 1316 Hemlock Street * Charlotte, NC 28203
(704)376-8550

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