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WE ARE HERE
FOR YOU

Single mothers in Los Angeles who are interested in receiving the resources and support provided by SHE IS HOPE LA can fill out an intake form to schedule a call with a trusted advisor.

 

To get started, please fill out the intake form below. Once you submit the form, you will be directed to schedule a call with one of our knowledgeable and compassionate advisors, who can provide you with tailored support and advice. We look forward to connecting with you and helping your family create hope for the future.

 

Thank you!

SINGLE MOTHER INTAKE FORM
Do you have a safe place to stay?
Do you have any pets?
Which race or ethnicity best describes you? (Please choose only one.)
What are your preferred pronouns?
What is your status?
Are you currently dating or in a reationship with anyone other than the children's father?
Anyone living in your household besides you and your children?
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Are your children in school? Check all that apply:
Are any of your children in IEP?
Do your children have any special needs?
Are you or your children in therapy?
Are you or your children a client of the Regional Center?
Do you receive child support?
What is your child custody status?
Are you getting government assistance? If so, what programs?
What type of assistance are you in need of?
What type of transportation do you use:
Are you currently employed?
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Are you interested in any of the following:
Please indicate any special areas of need for yourself:
Do you have a history of any legal charges?
Are you on probation or parole?
Do you have a history of substance and/or alcohol abuse?
Are you currently experiencing ay issues with substance and/or alcohol abuse?
Are you seeking treatment or need help with substance and/or alcohol abuse?
Have you experienced physical, sexual or emotional abuse?
Are you seeking treatment or need help with physical, emotional or sexual abuse?
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