Oak Cottage For Women Application V1

The Oak Cottage For Women
P.O. Box 216
Franklin, TN. 37065-0216

Name*

First NameLast Name

Date*

Date

Each question & section of this application must be completed to be considered for approval.

A woman 18 years of olderCurrently incarcerated in the State of Tennessee correctional facilityMust be ambulatory and able to do own activities of daily living (dressing bathing, feeding)Willing/able to work up to 29-40 hours per week in order to pay program fees ($150 weekly)Willing to participate in employment, volunteering, educational courses or other daily programs (outside of The Oak Cottage for Women)Has at least 6 months' substance free and able to pass a drug screen and breathalyzer upon admission.Willing/able to pay $150 Nonrefundable deposit to be admitted.

Name*

First NameLast Name

TDOC/Inmate Number*

Inmate Number

Birth Date*

Date

Age*

Age

Marital Status*

Personal Information (provide prison address)*

Street Address

How Long?

CityState / Province

Postal / Zip CodeCountry

Medical History

Medical History: Any information provided will be protected and will not be shared with individuals without written consent by the applicant.

Medications

Rows	Medication	Reason for taking	Dosage	Times per day	Date Prescribed
1
2
3
4
5
6
7
8

Residents will be responsible for their mental and medical health needs and will take their medications on their own as they are prescribed.

YesNo

If "yes" to what?

Allergies

Do You have any chronic medical conditions (i.e. high BP,diabetes, thyroid, etc?)*

Chronic Medical Conditions

Have you ever been told you needed surgery for a medical condition? If so what?*

Did you have the surgery and if so when and what was the surgery for?*

YesNo

If so, what is the expected due date?

Due Date

YesNo

If Yes, what is the amount of child support you owe? If no, enter $0*

Child Support Owed

What is your monthly Child Support Payment Amount? Enter $0 if you do not owe Child Support Payments.*

Monthly child support payment

YesNo

Mental Health History

YesNo

If yes, what is your historical or current mental health diagnosis?

Mental health diagnosis

YesNo

If yes, please describe when and how you thought or attempted in the past.

Substance Use/Abuse History

Alcohol Use

YesNo

What age did you start drinking?

Age

How long have you been drinking?

When was you last drink?

YesNo

If yes, when, and where?

Treatment for alcohol

What were the consequences of your use?

Drug Use

YesNo

What was or is your drug(s) of choice?

Drug(s) of choice

What age did you start using drugs?

Age

How long did or have you used drugs?

How often would you use?

When did you last use?

YesNo

If yes, when and where?

What were the consequences of your use?

YesNo

Legal Issues

YesNo

Incarceration History

What are your current charges?*

YesNo

If yes, how many?

If yes, identify to write-up(s) and explain

When was you most recent write up?

Recent write-up

YesNo

If yes, what date do you go up for parole?

YesNo

If yes, what is the pending release date?

pending release date

Yes

NO PERSON WILL BE EXCLUDED ON THE BASIS OR RACE, COLOR, NATIONAL ORIGIN, RELIGION, DISABILITY, FAMILIAL STATUS OR SEX

COLLATERAL CONTACT INFORMATION

In order for us to facilitate your possible admittance into our program, we must have a way to obtain informaiton regarding your release. Please provide the anme of phone number of a corrections staff member whom we may contact.

Corrections staff member name*

First NameLast Name

Corrections staff member phone number*

Area CodePhone Number

Corrections staff member position (case manager/counselor/Sgt./etc.)*

Position

Employment Background

All residents MUST find employment and maintian at least 29-40 hours per week. Jobs will be daytime jobs and curfew is 5:30 p.m. because of public transportation passes and nightly meetings. These meetings include: Job training, life skills, financial responsibility, addiction therapy, etc.

YesNo

Last year employed?*

Where?*

What kind of work have you done in the past?*

YesNo

ApprovedPlanning to reapply

Support documents must be provided of current status before admission decision can be made.

Emergency Contact Information

If I am approved for residency, I give The Oak Cottage for Women, Inc. permission to contact the following individual in the event of an emergency and to assist in arranging transportation to The Oak Cottage For Women, Inc.

Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Address*

Street Address

CityState / Province

Postal / Zip Code

I agree that the information provided is true and accurate to my knowledge. I give The Oak Cottage For Women permission to use the information given to make a decision regarding my acceptance into the program or to help with my admission date and/or transportation. I further understand that if I am approved, I will be expected to be compliant with the program guidelines.

Signed

Date*

Date

Mail the printed form to:

The Oak Cottage For Women
P.O. Box 216
Franklin, TN. 37065-0216

Application For Re-Entry Program