Ruth Harbor Ministries Application

Homes where God’s love transforms lives.

Ruth Harbor Admission Application

Download a printable copy of the full PDF application form.

Specify Program

Select which program you are interested in enrolling: Maternity New Mom Mother-Child

If selecting Maternity, what is your expected due date?

If selecting New Mom/Mother-Child, when is your child's date of birth?

Applicant Information (Birthmother)

This field must be a valid email address.

Do you want to come to Ruth Harbor: Yes No

Are you a US Citizen? Yes No

Does your family speak and understand English: Yes No

Are you a: morning person night person

Are you a more: outgoing people person who likes to be with other people quiet person who likes to stay more to yourself

Education Information

Have you completed high school or a GED? Yes No

Have you ever been suspended or expelled from school: Yes No

Do you like school: Yes No

Residents who have not received their high school diploma or GED are encouraged to enroll, with House Parent assistance, in the G.E.D. program at the local community college or attend middle or high school.

Family Information

Current living situation: Residing with parents/guardians Living Independently Other – explain below

Has either of your parents remarried? Yes No

Father or Father-Figure of Applicant

This field must be a valid email address.

Are you now or have you ever been involved in a family or dating relationship that was violent (physically, sexually, or emotionally)? Yes No

Did you receive any counseling for this? Yes No

Employment Information

Are you currently employed? Yes No

Have you ever been fired from a job? Yes No

Previous Employment (Please list previous employers & length of employment at each)

Legal

Are you involved with any court proceedings at this time? Yes No

Have you ever had any involvement with DHS during your upbringing? Yes No

Have you ever been or are you currently on probation? Yes No

Spiritual

Did you attend a church while growing up? Yes No

Are you willing to attend church with the House Parents while at Ruth Harbor? Yes No

Do you have a Bible? Yes No

Do you consider yourself to be a Christian? Yes No

Medical Information

Have you been on any medication in the last 6 months? Yes No

Have you used any of the substances listed below in the last 6 months? (Check all that apply) Alcohol Marijuana Street Drugs Prescription Drugs Meth Other (specify)

Are you willing to quit smoking while at Ruth Harbor if you are currently a smoker? Yes No

Do you have any other special medical problems or other situations that we should be aware of (diabetes, etc.)? Yes No

Maternity Health [For Maternity Applicants: If applying for the New Mom/Mother-Child Program, skip to FINANCIAL INFORMATION]

Is your family aware of your pregnancy? Yes No

Are you currently receiving prenatal care? Yes No

Have you been pregnant before? Yes No

Was it your choice to become sexually active? Yes No

Have you ever been treated for STDs? Yes No

Financial Information

If you are insured or covered under an individual or family policy, please complete the following:

Please check all that apply: I have Title IXX (Medicaid) now I am planning to apply for Title IXX (Medicaid) I need information about Title IXX (Medicaid) I do not want to apply or do not qualify for Title IXX (Medicaid) I do not have any insurance or medical coverage Other (please explain):

If you do not have insurance, you may be eligible for Title IXX (Medicaid) or other state government coverage. Please bring the following when you arrive for check in at Ruth Harbor. We have a copier so you can bring the original documents if you want.
-Social Security Card
-Copy of Birth Certificate

Are you on WIC? Yes No

Are you currently on FIP? Yes No

Father of the Baby Information

Is the father of the baby aware of your desire to come to Ruth Harbor? Yes No

Does the father of the baby support your coming to Ruth Harbor? Yes No

Does he have a job? Yes No

Do you have a boyfriend who is not the father of the baby? Yes No

Support System

Child’s Information [Complete if applying for the Mother-Child Program; If applying for Maternity Program, skip ahead to SIGNATURES below]

Child’s Medical Information

Is your child currently taking any medications? Yes No

Does your child currently have any known medical conditions? Yes No

Insurance Coverage: Title IXX Family/Other

Child’s Legal Information [Complete if applying for the Mother/Child Program]

Has DHS ever been involved with the child? Yes No

By submitting below, I verify that all information is correct and accurate on this application.

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Homes where God’s love transforms lives.

Ruth Harbor Ministries
534 42nd Street
Des Moines, IA 50312
Phone: 515-279-4661
Fax: 515-633-2157
M-F 8:30 AM-5 PM
info@ruthharbor.org

Homes where God’s love transforms lives.

Ruth Harbor Admission Application

Specify Program

Applicant Information (Birthmother)

Education Information

Family Information

Father or Father-Figure of Applicant

Mother or Mother-Figure of Applicant

Relationships

Employment Information

Legal

Spiritual

Medical Information

Maternity Health [For Maternity Applicants: If applying for the New Mom/Mother-Child Program, skip to FINANCIAL INFORMATION]

Financial Information

Father of the Baby Information

Support System

Child’s Information [Complete if applying for the Mother-Child Program; If applying for Maternity Program, skip ahead to SIGNATURES below]

Child’s Medical Information

Child’s Legal Information [Complete if applying for the Mother/Child Program]