Thank you for scheduling your initial visit. In order to expedite the check-in process, please complete this form before your visit. Date: Is this your first visit to Loreto House? yesno If no, when did you last visit? Date of Birth: Date: Is this your first visit to Loreto House? yesno If no, when did you last visit? Date of Birth: First Name: (required) Home Phone Number: Street Address: State: AlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Email: Last Name: (required) Cellphone Number: City: Zip Code: Reason for your visit? Initial visit, seeking pregnancy test.Initial visit, consultation for ultrasound.Initial visit, seeking counseling, material goods or classes.Initial visit for information about options if pregnant.Existing client for repeat pregnancy test.Existing client for educational class or counseling.Existing client for consultation for future ultrasound. If you are pregnant, have you received any prenatal care? YesNoDoes Not Apply Have you ever had any of the following? MiscarriageAbortionStillbirth For Guests Seeking a Pregnancy Test 1. First Day of your last period? 2. Are you using birth control? If yes, what type? 3. Last OB/GYN visit? Physician's Name? 4. Have you done a pregnancy test? If yes, what was the result? No test takenPositiveNegative 5. Have you been tested for sexually transmitted infections? If yes, what was the diagnosis, if any? 6. Has your partner been tested for sexually transmitted infections? If yes, what was the diagnosis, if any? Number of children? Names and Ages of Children? Birthday of youngest child? Relationship Status: SingleMarriedDivorcedSeparatedLiving TogetherOther Do you feel safe in your current situation? YesNo With whom do you live? What is their relationship to you? Education: No high schoolSome high schoolHigh school diploma/GEDSome collegeCollege DegreeSome vocational schoolVocational certificateOther Race or origin: American Indian/Alaskan NativeAsianBlack or African AmericanCaucasian/WhiteHispanic, Latino or SpanishNative Hawaiian or Pacific IslanderOther Are you a U.S. Citizen or qualified alien? *Please note, our services are available to you no matter how you answer. Staff can provide a form that explains the definition of a qualified alien if you request it. YesNo What is your primary language? What is your religious preference? Are you currently working? If yes, what is your occupation? What outside help are you receiving? Child supportMedicaidInsuranceWICFamily helpCHIPFriendsSNAPChurchOther What do you need help with at this time? Baby goodsClothingFoodChildcareShelter/housingJobMedicalDentalOther Are there any other concerns you'd like to share? Loreto House is not a medical clinic and our staff and volunteers are not qualified to diagnose conditions or provide medical advice. Our pregnancy tests are done in compliance with Clinical Laboratory Improvement Amendments (CLIA) and we are authorized to perform urine specimen pregnancy testing. The above information is correct, and I request that Loreto House provide a pregnancy test and/or other services that may be appropriate. I authorize Loreto House staff and volunteers to contact me by phone, text, mail, or email using above contact information. Note: All information you provide to Loreto House is confidential and will not be released to a third party without your prior written authorization unless we are mandated by, or Court ordered to release information or, unless you report to us any of the following which law requires us to report: (1) threat of harm to self or others, (2) abuse of a child, (3) abuse of an elderly person. To accept, please check this box and click submit.