MH Family Application

FAMILY APPLICATION
Welcome to Mary’s Home

Our mission is to provide single-mother families faith-based community housing to gain supportive relationships, wholistic health, life skills, economic self-sufficiency, and community resources to be able to exit homelessness permanently. Our philosophy of care is Christ-centered, culturally sensitive, trauma-informed, boundaries based, and goal-oriented.

Eligilibility Requirements

Eligible applicants are single mothers with three or fewer children under ten years of age, who are homeless in Colorado Springs, who have a level of need Mary's Home can support, who are motivated to participate in a structured personal growth and career development program for six months to two years plus, and who are eligible for TANF and CCCAP. Please be sure to complete this application in it's entirety for the Admissions Team to review.

Application Process

Mary's Home does phone interviews with potential applicants prior to moving forward with applications. Completed applications are submitted online or sent to Mary's Home. All applicants receive an email response. Qualified applicants have a personal interview and submit documentation. Contact Mary's Home at 719.301.5411 (phone) or 719.301.5412 (fax) or email us at MarysHomeAdmissions@DreamCenters.com.
Applicant Information
Date*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Have you applied to Mary's Home in the past?
If yes, when did you last apply?

MonthDayYear
Date
How did you hear about Mary's Home? / Who referred you?*
List other housing programs you have been in and dates:
Other names under which you received services

First NameMiddle NameLast Name
Cell Phone Number*

Area CodePhone Number
Other Phone Number

Area CodePhone Number
Email*
example@example.com
Current Shelter
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant's Date of Birth*
Date of Birth

MonthDayYear
Date
Do you have a Driver's License? *
ID or DL #*
Are you a US Citizen?*
Race (Applicant)*
Relationship Status*
If you selected anything other than single, please describe.
Name of Current Ex-Partner or Spouse

First NameMiddle NameLast Name
Are you a Veteran; have you served in the US Military? *
Do you have a disabling condition? *
If yes, please describe:

Housing Information
Where did you stay last night?
Are you homeless or imminently homeless? *
How many months have you been continually homeless currently?
Have you been experiencing homelessness for one year or more?
How many times have you been homeless in the past 3 years? *
If you are currently housed, are you being evicted or asked to leave within 14days?
What is a contributing factor to your situation that has led you to being unhoused?
Have you ever experienced domestic violence or an aggressive relationship whether it was emotional, physical or verbal abuse with anyone, including family, friends or an intimate partner?
What is the last address where you lived for the last 90 days or more?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Resided at this address from:

MonthDayYear
Date
To

MonthDayYear
Date

Children's Information
Include all biological children:

For all of your children, please enter their first, middle and last name, sex, age, race, and name of father. If you have fewer than 3 children, please put a (-) in all boxes.
1. Name*

First NameMiddle NameLast Name
Child's Sex*
Child's Date of Birth *

MonthDayYear
Date
Child's Race*
Name of Father

First NameMiddle NameLast Name
2. Name

First NameMiddle NameLast Name
Child' s Sex
Child's Date of Birth

MonthDayYear
Date
Child's Race
Name of Father

First NameMiddle NameLast Name
3. Name

First NameMiddle NameLast Name
Child's Sex
Child's Date of Birth

MonthDayYear
Date
Child's Race
Name of Father

First NameMiddle NameLast Name

Children's Information Continued
Are your children US Citizens? *
Do you have at least 50% physical custody of your children you have listed on this application?
If no, please explain:
List first names of children who currently live with you:
Have you ever been investigated for child abuse?
If yes, list child's name, explain incidents and outcomes:
List each child's name and describe the relationship they have with their father:
List each child's name and describe legal custody, visitation activity and any safety concerns:
Explain how you want custody status and or visitation agreements to change:
Do any of the children you have listed on this application have a disabling condition?
If yes, please describe:

Family's Health Information
Does your family have Medicaid? *
Are you currently pregnant? *
If yes, what is your expected due date?

MonthDayYear
Date
Father's Name

First NameMiddle NameLast Name
Mental Health History
Are you currently or have you previously received services for any mental health diagnoses?
If yes, what was/are the diagnoses, dates of service and outcomes?
List all medications that mother is prescribed:
Have you been hospitalized for mental health?
If yes, please explain and include dates of service.
Has your child(ren) ever received or are currently receiving services for mental health diagnoses?
If yes, what was/are the diagnoses, dates of service and outcomes:
List all medications that child(ren) is/are prescribed:
Has your child(ren) been hospitalized for mental health?
If yes, please explain and include dates of service:
Have you ever used harmful or illegal substances?
If yes, what, how much have you used and dates of most recent substance use:
When was the last time you consumed alcohol?

MonthDayYear
Date
When was the last time you used marijuana?

MonthDayYear
Date
Do you use cigarettes or vape?
Are you willing to quit using tobacco products?
If yes, how do you plan to quit?
Has your child(ren) ever been exposed to harmful/illegal substances?
If yes, please explain:
Has your child(ren) ever been exposed to alcohol misuse?
If yes, please explain:
Have you or your child(ren) ever received treatment for alcohol misuse or substance use disorder?
If yes, please explain:

Education and Training History
Applicant's Highest level of education completed:*
Describe your future plans for school, area of study, and career:
List child's name, highest grade completed, current or last school or child care name, eligibility for school or childcare:
List any issues, problems or concerns with children attending school and/or childcare full-time:

Employment History
Current Employment Status
What is the longest length of employment that you have sustained a paid position with one employer?
Where were you most recently employed?
When was your last date of employment?

MonthDayYear
Date
Just a Note:

We ask that mothers accepted into Mary’s Home commit to not working during their first six months in the program. As a holistic program, our primary focus during this time is on healing from trauma, building strong life skills, strengthening parenting, and establishing a stable foundation for long-term success. This dedicated period allows each mom to fully engage in counseling, classes, and community life without the added pressures of outside employment.

Transportation
Do you own a vehicle?
Is the Vehicle Title in your name?
Are you the only person listed on the Vehicle Title?
Do you use a friend or family member's vehicle for regular use?
What is:
Vehicle Make
Model
License Plate Number
Condition
Insurance
Policy Number
Do you know how to use the public bus?
If no, are you willing to learn?

Finances
Are you eligible to receive TANF, SNAP or CCCAP public assistance? *
If no, explain reason
If yes, list current monthly amounts
Are you currently receiving child support?
If no, explain reason. If yes, list current monthly amounts:
List any other source of income and amounts:
Do you currently have a cellphone?
If yes, monthly bill:
$
Do you currently have a checking account, savingss account, ATM card or a credit card?
If yes, describe:
Do you currently owe money to any bank?
If yes, list bank names and amounts:
List any other debt that you have including school debt, legal fees, etc:
Do you currently have a budget?
What are your short-term and long-term financial goals?

Legal Information
Have you ever been arrested, charged or convicted of any drug or alcohol related offense?
If yes, dates, city, and offense?
Have you ever been arrested, charged or convicted of a crime?
If yes, dates, city, and outcome?
Are you currently on probation or parole?
Are you currently awaiting sentencing?
Please explain ALL details related to parole, probation or sentencing:
Have you ever been involved with a gang?
If yes, please explain:
Are you currently involved, or have you ever been involved, in a custody case regarding your child(ren)?
If yes, please explain:
Are you currently, or have you ever, been involved with DHS?
If yes, please explain:
Are you willing to establish legal custody of your child(ren)?

Family Lifestyle
What is your personal opinion about faith and church?
Describe what you know about God?
What types of churches have you been a part of in your life?
Do you have a schedule-routine established with your child(ren)?
What time do you go to bed and what time do your children go to bed?
What do you and your children like to do for relaxation?
How is your family currently involved in your life?
How are your friends currently involved in your life?
Do you like time with people or time alone to get renewed?
What's the hardest thing for you about people?
Why do you want to join the Mary's Home community?
How long do you desire to live at Mary's Home?
What do you want to learn and accomplish at Mary's Home?
What will be the biggest challenge for you if you live at Mary's Home?
What is your plan for housing and care for your family if you are not accepted into Mary's Home or you don't like it?

Personal References

List two references (personal or professional) who Mary's Home is allowed to contact regarding your application.
Name

First NameLast Name
Relationship
Phone

Area CodePhone Number
Length of Time Known
Name

First NameLast Name
Relationship
Phone

Area CodePhone Number
Length of Time Known
MOTHER’S PERMISSION FOR RELEASE OF FAMILY INFORMATION

I GIVE MARY’S HOME PERMISSION TO CONTACT ALL REFERRALS AND REFERENCES AND TO RUN A CRIMINAL BACKGROUND CHECK AND A MOTOR VEHICLE RECORDS CHECK. I WILL SIGN AND SUBMIT THE PIKES PEAK REGION COMBINED AGENCY INFORMED CONSENT RELEASE TO BE USED IN THE APPLICATION PROCESS. I UNDERSTAND THAT IF I FAIL TO PROVIDE WRITTEN PERMISSION, MY APPLICATION WILL NOT BE PROCESSED.
Electronic Signature*

First NameMiddle NameLast Name
Date*

MonthDayYear
Date
ATTEST OF INFORMATION

I attest that all the information provided in this application is honest and accurate to the best of my knowledge. I understand that any deliberate misrepresentation of the information could result in my being denied acceptance into or expelled from this program.
Electronic Signature*

First NameMiddle NameLast Name
Date*

MonthDayYear
Date
Thank you for completing this application to Mary’s Home. We will notify you of the status of your application as soon as possible. May God bless you and encourage you and your children in your life journey.

Mary’s Home to the extent possible assures all applicants of confidential treatment of personal information. Mary’s Home shall obtain written permission for the release of information, unless the law otherwise authorizes such release. Limited information is used for anonymous statistical purposes for the purpose of increasing supportive services to homeless populations.
The Section Below is for Application Review-Office Use Only Please scroll to the bottom to click submit
Date Application Received
Release of Information Status
Application Status/Comments
Date Application Packet Reviewed
Outcome
Notification Date
Admit Date
Should be Empty:

Applicant Information

Housing Information

Children's Information

Mental Health History

Education and Training History

Employment History

Transportation

Finances

Legal Information

Family Lifestyle

Personal References