Questionnaire for the Professional Member


The following questions are intended to provide us with important biographical information
about you that will help ensure us of making a good match with client needs when assigning your professional services.

---

	Date	/ /
A. Basic Information
	Name        Date of birth:
	Home Address
	City/State Zip
	Home phone:    ()      Fax:    ()
	Business Address
	City/State Zip
	Business phone:    ()      Fax:    ()
	Email address
	Current position or title:
B. The Goals of the Nurturing Network
	The Nurturing Network is dedicated to helping any woman with an unplanned pregnancy give life to her unborn child. In particular, the Network seeks to provide a positive alternative to abortion that meets the specific needs of a woman facing a crisis pregnancy in the midst of her education or career. Because the women we serve are vulnerable at this particular time in their lives, it is important that all members reinforce the support and understanding we offer.
	Have you read the Member and Client brochures of The Nurturing Network? Yes No
	Do you feel you understand the general purposes of our organization? Yes No
	Are you comfortable reinforcing the goals of the Network in your daily contact with our Client(s)? Yes No
	Do you believe that you can offer the supportive care that our client(s) may need? Yes No
	If you answered "No" to any of these questions, please explain