Mother 2 Mother

NAME: ________________________________________________DATE: _________________________ AGE: __________RACE:__________SEX:___________SS#______________TELEPHONE # _____________________ REFERRING AGENCY: ____________________________________________________________________ QUESTION Are you homeless? Would you pass a drug screen today? Do you live in Metro Atlanta? If no, where? Are you a past resident of Mother 2 Mother? Do you have any health concerns? Are you pregnant? How many weeks? Mental health concerns? Are you on any medications? Any legal matters/arrests/convictions? Violent past/Restraining orders? Drug abuse history? Have you ever used drugs in the past? How long have you been clean? Do you have legal right to reside and work in the US? Are you working? If yes, where? Are you able to work? Utilized rental/utility assistance before? If yes, please explain. SSI/SSD income? If yes, how much? SSI/SSD pending? YES NO COMMENTS

Names of ALL family members (Oldest to youngest)

DOB

Male/ Female

Relationship

Any Special needs?

Staff Signature: _________________________________________________

Date: _________________

At Mother 2 Mother, our mission is to provide a safe and stable environment for single, homeless mothers and mothers to be, and to give them access to the necessary tools to provide for themselves and their children. We aim to provide a place for homeless mothers and mothers to be a safe and clean environment to live in until they are back on their feet. In our shelter, we will provide a clean bed for mother and child, clothes if necessary, food, and comfort. In our shelter, we want to be culturally blind, and accommodate anyone who is in need, and provide the essentials for each individual, which will range from culture to culture. After the intake process is complete and the mother and child have settled in, our mothers will be paired with a case manager, and together they will come up with a plan for her future success. A requirement for our shelter is that all mothers who do not have a job or is not a student in college must be looking for reliable, steady income. We will provide on-site day care for children who are not in school, while the mothers are out looking for reliable employment. While meeting with their case managers, goals will be established for the future, and they will work with their case manager to work towards these goals. The case managers will hold them accountable and work with them every step of the way. Upon completion of the program, the mothers will be provided off-site transitional housing through Mother 2 Mother. The requirement for transitional housing is that they have completed all of their goals with their case managers, and have shown that they are able to take care of themselves and their children on their own. The mothers will pay 30% of their income for that month, and they will be referred to a day care for their children. There is a maximum stay of up to 2 years in the transitional housing. Skills that will be learned are: 1. 2. 3. 4. 5. Life skills Money Management Resume Building Job Interviewing Pre-natal care (if necessary)