We’re here to help.

We’re so glad that you found the Lewis County Maternity House and that this transitional home might be the right fit for you in this season of your life! While we can’t guarantee a space is available in the home, if there is room available at the LC Maternity House we will reach out to you to set up a tour of the home and a chance to meet the team and learn how the house operates before signing a rental agreement.

Application Form

Name

First Name

Last Name

Email

Referring Organization

Please list the referral organization name and contact information.

Referral Name

First Name

Last Name

Referral Date Of Birth

MM

DD

YYYY

Referral Email

Referral Phone

(###)

###

####

What type of support does your organization currently provide this referred client?

Message

Tell us why you're referring this client.

Maternity House Application Rental

Name

First Name

Last Name

Email

Phone

(###)

###

####

Are you currently pregnant?

Yes

No

How many weeks pregnant are you?

Do you currently have kids in your custody?

Yes

No

What is your birthday?

MM

DD

YYYY

Tell us about your current housing situation:

What city and state do you currently reside in?

Have you ever been arrested or convicted of a crime?

If yes, please explain:

Please list medications you are currently taking:

Have you used any alcohol, drugs or other substances in the last 60 days (including non prescribed prescription meds)?

Have you been treated for substance abuse in the past?

If Yes, please tell us when.

Do you smoke or vape currently?

Yes

No

Why would you like to live at the Lewis County Maternity House?

Considering applying, but have questions? Here’s a few ways to ask questions:

Text Your Questions: 844-868-1849
Call: 360-736-6133
Email: taylor@cookshillcc.orgb