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WELCOME TO NEW LVL

EMPOWERMENT PROGRAM

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Empowering You to Rise, Renew, and Thrive

At New LVL, we believe every single mother deserves stability, confidence, and the resources to build a stronger future.

Our enrollment process helps us learn about your unique needs so we can connect you with personalized support — including housing referrals, financial literacy, workforce development, childcare resources, and mental wellness programs.

Completing this form is your first step toward joining a supportive community dedicated to helping you grow beyond challenges and reach your next level.

How to Complete Your Enrollment

Please read carefully before you begin:

Time Needed: About 10–15 minutes.

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Device Friendly: Complete on any phone, tablet, or computer.

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What You’ll Need: basic contact info, names and ages of your children, current housing and job status, childcare, transportation, and education details, basic financial information.

Cilent Information

Birthday
Month
Day
Year
Preferred Method of Contact
Phone
Email
Text
Areas of Need

Household & Family

Relationship Status
Single
Married
Divorced
Widowed
Are you the primary caregiver?
Yes
No
Do you currently receive child support?
Yes
No
Other
Do you have reliable childcare?
Yes
No
Other
Do your children attend school or daycare?
Yes
No
Other
Transportation to/from school
Bus
Walk
Parent drives
Carpool
Other

Housing & Living Situation

Current Living Situation
Renting an apartment/home
Living with family/friends
Temporary housing/shelter
Homeless/unsheltered
Do you have a lease in your name?
Yes
No
Are you at risk of losing your housing?
Yes
No
Desired Living Space Type
Apartment
House
Shared Unit
Transitional Housing
Other

Employment & Work Status

Current Employment Status
Full-time
Part-time
Self-employed
Unemployed
Student
Type of Work
In-Person
Remote
Hybrid
Do you receive benefits through your employer?
Yes
No
If yes, which?
Are you currently in school or a training program?
Would you like assistance finding a new or higher-paying job?

Transportation & Vehicle Information

Do you have a valid driver’s license?
Yes
No
Is the vehicle currently operational?
Yes
No
Do you have car insurance?
Yes
No

Financial Literacy & Economic Stability

Primary Income Source(s)
Employment
Self-Employment
Child Support
Public Assistance
Unemployment
Disability
Other

Current Monthly Expenses (estimate)

Do you currently have a checkings and savings?

Public Assistance & Benefit

Are you currently receiving any of the following? (Check all that apply)

Health & Wellness

Do you have health insurance?
Yes
No
Are you currently connected to a therapist or counselor?
Yes
No
Would you like mental health support or referrals?
Yes
No

Referral Source

How did you hear about New LVL?
Friend/Family
Community Organization
School
Social Media
Event
Other
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