Programs Pre-Qualification Form

To learn more about our programs and apply for assistance, please fill out the pre-qualification form below.


    Head of Household

    Fields with * are required.

    First Name*

    Middle Initial

    Last Name*

    Date of Birth*

    Age*

    Address*

    City*

    State*

    Zip Code*

    Phone Number*

    Email*


    Household Members (Significant Other, Children)

    Full Name

    Date of Birth

    Age

    Medical/Behavioral Background (ADHD, Autistic, EBD, Asthma, Outbursts, etc.)

    Add another household member?

    Household Member 2

    Full Name

    Date of Birth

    Age

    Medical/Behavioral Background (ADHD, Autistic, EBD, Asthma, Outbursts, etc.)

    Add another household member?

    Household Member 3

    Full Name

    Date of Birth

    Age

    Medical/Behavioral Background (ADHD, Autistic, EBD, Asthma, Outbursts, etc.)

    Add another household member?

    Household Member 4

    Full Name

    Date of Birth

    Age

    Medical/Behavioral Background (ADHD, Autistic, EBD, Asthma, Outbursts, etc.)

    If you have additional household members, please contact our office to provide that information.


    Preliminary Questions

    Are you under 27 years of age?*
    Do you have children between the ages of newborn and 9 years old?*
    Is there a crisis?*

    Please define the crisis.

    Does your family need support?*

    Please define the support you require.

    Are you willing to complete Strengthening Families Workshops?*


    Services

    What services do you need? Check all that apply.


    Who referred you to B.A.B.E.S., Inc.? Please list the name next to the referral type.

    Doctor

    Social Worker

    School

    Friend

    Caseworker

    Another Non-profit Organization

    Other


    Additional Information

    Please share with us any other pertinent information you would like to provide
    (i.e. current situation/crisis, domestic abuse, custody/placement, etc.)

    Disclaimer: Completing the program pre-qualification form does not guarantee admission to all programs and services offered by B.A.B.E.S., Inc. Child Abuse Prevention Program.