Mustard Seed Homes Application

Application
Personal Information
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
E-mail
Birth Date*

MonthDayYear
Social Security Number*
Are you a Veteran?*

YesNo
Marital Status*
Spouse's Name

Do you have a legal guardian?*

YesNo
Legal Guardian Name*
Legal Guardian Phone Number*
Legal Guardian Email
example@example.com
Legal Guardian Address*

Street Address

Street Address Line 2

CityState

Zip Code
Medical Insurance Provider*
Medical Insurance Provider Phone Number*
County of Financial Responsibility:*
Caseworker:*

Present Housing Situation:*

Live with SpouseLive with ParentsLive with a relativeLive with friendsIncarceratedTreatment FacilityHomelessLive aloneOther

Education
Have you received a High School Diploma?*

YesNo
Have you received your GED?*

YesNo
What is the highest grade you have completed?
Have you attended College?*

YesNo
College Name
City and State where College was located
What was your major area of study?
How many credits did you receive during your time in college?

Emergency Contact

Other than your Legal Guardian, if applicable.
Please select all that apply*

Family MemberFriendOther
Emergency Contact Name*

First NameLast Name
Emergency Contact Address*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact Home Phone Number

Area CodePhone Number
Emergency Contact Cell Phone Number*

Area CodePhone Number
Emergency Contact Email
example@example.com

Secondary Emergency Contact
Please select all that apply*

Family MemberFriendOther
Emergency Contact Name*

First NameLast Name
Emergency Contact Address*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact Home Phone Number

Area CodePhone Number
Emergency Contact Cell Phone Number*

Area CodePhone Number
Emergency Contact Email
example@example.com

Family Information
Mother's Name*

First NameLast Name
Mother's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mother's Home Phone Number

Area CodePhone Number
Mother's Cell Phone Number*

Area CodePhone Number
Mother's Email
example@example.com
Father's Name*

First NameLast Name
Father's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Father's Home Phone Number

Area CodePhone Number
Father's Cell Phone Number*

Area CodePhone Number
Father's Email
example@example.com
Spouse's Name*

First NameLast Name
Spouse's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Spouse's Home Phone Number

Area CodePhone Number
Spouse's Cell Phone Number*

Area CodePhone Number
Spouse's Email
example@example.com

Employment History

What were your last 3 jobs?
Company Name - Job 1*
Starting Date*

MonthDayYear
Date
Ending Date*

MonthDayYear
Date
Position*
Reason for leaving*
Company Name - Job 2*
Starting Date*

MonthDayYear
Date
Ending Date*

MonthDayYear
Date
Position*
Reason for leaving*
Company Name - Job 3*
Starting Date*

MonthDayYear
Date
Ending Date*

MonthDayYear
Date
Position*
Reason for leaving*

Religious Beliefs
What religion do you currently practice?*
If none, say 'None'
Name of Church
If applicable
Church Address

Street Address

Street Address Line 2

CityState

Zip Code
Pastor's Name

First NameLast Name
Church Phone Number

Area CodePhone Number

Life Story

Write a brief biography of your life, including your spiritual experiences. We want to get to know you better and we know it can be difficult to sum up your life. If you get stuck or don't know where to start, try thinking about your life a year at a time.

Medical Information
Present medical information/ concerns:*
Write "None", if none.
Are you currently taking any medications? If Yes, list your medications and dosages below.*

YesNo
Medication 1:
Dosage
Medication 2:
Dosage
Medication 3:
Dosage
Medical Doctor*

First NameLast Name
Clinic Name*
Clinic Address*

Street Address

Street Address Line 2

CityState

Zip Code
Clinic Phone Number*

Area CodePhone Number
Do you have a Mental Health Provider?*

YesNo
Mental Health Provider Name*

First NameLast Name
Mental Health Provider Clinic Name*
Mental Health Provider Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mental Health Provider Phone Number*

Area CodePhone Number

Chemical Dependency
Chemical/Drug of choice:*
Date of last use:*
How often did you use?*
Do you have a current desire to use?*

YesNo
Longest period of sobriety?*
Please list your previous/current treatment program(s) including the city where attended.*
Contact person at last treatment program?*

First NameLast Name
Phone Number*

Area CodePhone Number
What is your relapse pattern?*
Do you have a relapse prevention program?*

YesNo
What is it?

Interest
Why are you interested in being a part of the Mustard Seed Homes program? *
Who has encouraged you to become a part of Mustard Seed Homes?*

Signature and Submission
Once you submit this application to Clear Waters Life Center, the program director and Mustard Seed Homes committee will review your application. We will contact you regarding your acceptance or non-acceptance into the Mustard Seed Homes Program.

Please type your name below and click Submit to authorize Mustard Seed Homes to contact any individuals named in this application and to obtain a criminal background check.
Full Name*
Signature*

Clear
Date*

MonthDayYear
Enter the message as it's shown*
Should be Empty: