Apply For Services

To apply for services click to  download our application for services for Mom or Dad

Please note that your information is saved on our server as you enter it.
  • Mother’s General Information

    Which number should we use to contact you?
  • Date Format: MM slash DD slash YYYY
  • Fathers General Information

    Which number should we use to contact you?
  • Date Format: MM slash DD slash YYYY
  • Please describe the diagnosed Illness.
  • Power of Attorney

    THE FOLLOWING QUESTIONS ARE TO BE ANSWERED BY THE PATIENT
  • Date Format: DD slash MM slash YYYY
  • Family Information

  • Number of dependent children (under the age of 18):
  • Total Number of children, including those over 18:
  • Names and ages of children:
    NameAge 
  • Additional Information

  • Required Signatures

  • I understand and agree:

    1) That no promises or assurances whatsoever have been made to me by any representative of the Let There Be Mom organization regarding providing any services to me or my family;

    2) That granting services of any kind is contingent upon approval by the Let There Be Mom organization and my physician, as well as full compliance with all conditions, qualifications, and restrictions designated by the Let There Be Mom organization;

    3) That all individuals with parental or custodial rights for the children must approve participation with the Let There Be Mom organization and sign all necessary documents before services can begin; and

    4) That full disclosure of anyone having power-of-attorney over me must be made and they must complete the appropriate documents before the Let There Be Mom organization will consider offering services to me. I promise that the information provided by me is true and complete to the best of my knowledge.

  • Clear Signature
    Patient’s Signature
  • Clear Signature
    Power of Attorney Signature
  • This field is for validation purposes and should be left unchanged.