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.Format: (000) 000-0000.
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
Veteran status
Legal Information
Are you a convicted sex-offender?
Have you ever been incarcerated?
If yes, why and when were you incarcerated? If no, write N/A.
Do you have any pending legal issues or court dates?
If yes, please give specific details. If no, write N/A.
Attorney's Name
Attorney's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Attorney's Email
example@example.com
Attorney's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Probation:
Parole:
Probation/Parole Officer's name
Probation/Parole Officer's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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
Bondsman's Name
Bondsman's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Children
Do you have children?
Please complete the information below.
If yes, do your children live with you?
Do you have an open CPS case?
Are you seeking to get your children back?
Do you pay/owe child support?
Do you receive a child support check?
Parents
Mother's Full Name
Mother's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Siblings
Education
High School
High School Graduate?
GED?
College or University
College or University Graduate?
Mental Health Information
Have you ever been diagnosed with a mental health condition?
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.Format: (000) 000-0000.
Medical Information
Do you have a medical condition that requires a doctor's care and/or medication?
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.Format: (000) 000-0000.
Substance Abuse Information
Have you ever been in a recovery program/mission?
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?

Other
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?
When is the last time you used and what did you use?
Have you been through detox?
Do you use tobacco? (Tobacco is permitted but not provided. No vaping is allowed. No smoking underage.)
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?

Other
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.
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