Resident Application

Resident Application

This application MUST be filled out completely and honestly. "Surprises" in your potential interview or, if accepted, may interfere with your acceptance and/or residency.
Resident
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Social Security Number*
Driver's License Number*
Driver's License State*
Please specify your ethnicity*
Age
Height
Weight
Marital Status*

SingleMarriedDivorcedWidowedNever married
Veteran status*
Legal Information
Are you a convicted sex-offender?*

YesNo
Have you ever been incarcerated?*

YesNo
If yes, why and when were you incarcerated? If no, write N/A.*
Do you have any pending legal issues or court dates?*

YesNo
If yes, please give specific details. If no, write N/A.*
Attorney's Name*
Attorney's Phone Number*
Please enter a valid phone number.
Attorney's Email*
example@example.com
Attorney's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Probation:*

YesNo
Parole:*

YesNo
Probation/Parole Officer's name*
Probation/Parole Officer's Phone Number*
Please enter a valid phone number.
Probation/Parole Officer's Email*
example@example.com
Probation/Parole Officer's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Length of Probation/Parole*
How often do you report?*
Bondsman*

YesNo
Bondsman's Name*
Bondsman's Phone Number*
Please enter a valid phone number.
Bondsman's Email*
example@example.com
Significant Other

Understand that all relationships must become secondary to your program while at Graciously Broken Ministries.
Full Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Children
Do you have children?*

YesNo
Please complete the information below.
If yes, do your children live with you?*

YesNoNot Applicable
Do you have an open CPS case?*

YesNoNot Applicable
Are you seeking to get your children back?*

YesNoNot Applicable
Do you pay/owe child support?*

YesNo
Do you receive a child support check?*

YesNo
Parents
Mother's Full Name
Mother's Phone Number
Please enter a valid phone number.
Mother's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Full Name
Father's Phone Number
Please enter a valid phone number.
Father's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
Name
Relation to Resident
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Siblings
Education
High School
High School Graduate?

YesNo
GED?

YesNo
College or University
College or University Graduate?

YesNo
Mental Health Information
Have you ever been diagnosed with a mental health condition?*

YesNo
If yes, what is your mental health diagnosis? If no, write N/A.*
Please list the current mental health medications you are prescribed. If you have not been prescribed, write N/A.*
Psychiatrist's Full Name
Phone Number
Please enter a valid phone number.
Medical Information
Do you have a medical condition that requires a doctor's care and/or medication?*

YesNo
If yes, what is your medical diagnosis? If no, write N/A.*
Please list all current medications prescribed for your medical condition. If no, write N/A.*
Primary Care Physician's Full Name
Phone Number
Please enter a valid phone number.
Substance Abuse Information
Have you ever been in a recovery program/mission?*

YesNo
If you answered "YES", you have been in a recovery program/mission, answer the following questions honestly and thoroughly.
List all recovery programs/missions you have been to, when, and how long you stayed each time. (If no, type "NA")*
What was your exact reason for leaving?*
What is your drug(s) of choice?*

AlcoholMethamphetamineHeroineBenzodiazepineOther
What other drugs have you used or currently use? (Ex: Amphetamines, Adderall, Cocaine, Methadone, Oxy, Hydro, Fentanyl, Suboxone, Xanax, Valium, Klonipin, Marijuana)*
What is the longest you have been clean?*

0 - 6 months7 - 9 months10 - 18 months19 months - multiple years
When is the last time you used and what did you use?*
Have you been through detox?*

YesNo
Do you use tobacco? (Tobacco is permitted but not provided. No vaping is allowed. No smoking underage.)*

YesNo
Your Story, Your Future
Write a paragraph on why you want to enter the program.*
List 5 goals you want to see accomplished by your graduation of Graciously Broken.*
What are your dreams for your future? (Ex. "In 5 years, my desire is to..."*
Is there anything else that you feel we need to know?*
What do you believe about God? (Be honest. It does not determine your acceptance or denial in the program.)*
Who do you say Jesus is? (Be honest. It does not determine your acceptance or denial in the program.)*
If you could choose when you enter the program, when would it be?*

MonthDayYear
Date
Reference
How did you hear about us?*

Friend or FamilyCourt system (jail, probation or parole officer, judge, etc.)Social MediaOnline searchOther
Who referred you to Graciously Broken Ministries, Inc.?
I certify that all the information that I have stated is true to the best of my knowledge. I also understand that a background check might be done and I may recieve random drug testing and inspections. *

Clear
Should be Empty:

Resident Application

Resident

Legal Information

Significant Other

Children

Parents

Emergency Contact

Siblings

Education

Mental Health Information

Medical Information

Substance Abuse Information

Your Story, Your Future

Reference