Pregnancy Support Application - Mountain Heart Ministries

First Name *

Last Name *

Email Address *

Best Phone Number *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal code *

Pregnancy & Family Information

What type of pregnancy-related assistance are you seeking? *Currently pregnantRecently gave birthCaring for an infantExpectant father seeking assistanceOther pregnancy/family-related need

What is your expected due date or your baby's date of birth? *If you are currently pregnant, enter your expected due date. If your baby has already been born, enter the baby's date of birth.

Do you currently have access to appropriate prenatal care or medical care for you and your baby? *YesNoI need help finding care

How many people currently live in your household, including yourself? *

How many children under age 18 currently live in your household? *Enter 0 if there are no other children in the household.

Please tell us specifically what you need and how this assistance would help you and your baby. *Please include any details that will help us understand your current situation and your most important needs.

What is your household's approximate total monthly income? *Include income received by everyone in the household, such as wages, Social Security, SSI/SSDI, child support, or other regular income. Enter numbers only — do not use a dollar sign or commas. Example: Enter 1000 instead of $1,000.

Are you currently receiving assistance or services from any of the following? *Medicaid/TennCare or Kentucky MedicaidPregnancy resource centerFood pantryChurch or other ministryFamily or friendsOther community assistancePrenatal/medical care accessNone of the above

Do you currently have a safe and stable place for your family and baby to live? *YesNoTemporarily, but my housing situation is uncertain

Do you have reliable transportation for medical appointments and other essential needs? *YesNoSometimes/transportation is unreliable

Are any of the following affecting your current situation? *Recent job loss or reduction in work hoursUnexpected expensesLack of family or other supportHousing instabilityTransportation problemsDifficulty obtaining needed baby suppliesNone of the above

What do you believe would help you and your family become more stable going forward?This might include employment, education or job training, reliable transportation, stable housing, childcare, budgeting help, or another type of support.

Would you be interested in education, technical training, or job-skills training that could help you build a more secure future for your family? *YesMaybe - I would like more informationNo, not at this time

If yes or maybe, what type of education, career, or job training would interest you? *t's okay if you aren't sure. Tell us about the kind of work you might be interested in, and we may be able to help you explore available options.

How soon do you need the assistance you are requesting? *Immediately — within 24–48 hoursWithin one weekWithin two weeksWithin 30 daysNo specific deadline

Do you have another parent, family member, or caregiver who is able to regularly help with the baby's needs? *YesSome help, but it is limitedNo

Is there anything else about your situation that you would like Mountain Heart Ministries to know?Please share any additional information that may help us better understand your needs.

What is the best way for Mountain Heart Ministries to contact you about your application? *Phone callText messageEmail

Verification Authorization *I authorize Mountain Heart Ministries to verify the information provided in this application with appropriate individuals, organizations, agencies, service providers, or other sources when necessary to evaluate my request for assistance.

Applicant Certification *I certify that the information I have provided in this application is true and complete to the best of my knowledge. I understand that providing false or misleading information may result in my request being denied.

Assistance Acknowledgment *I understand that submitting this application does not guarantee that Mountain Heart Ministries will provide assistance. Requests are reviewed based on individual circumstances, available resources, and the ministry’s ability to help.

Electronic Signature — Please type your full legal name *By typing my name below, I acknowledge that this serves as my electronic signature on this application.

Date *