Mustard Seed Homes Application

Application
Personal Information
Full Name *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *

Area Code Phone Number
E-mail
Birth Date *

Month Day Year
Social Security Number *
Are you a Veteran? *

Yes No
Marital Status *
Spouse's Name

Do you have a legal guardian? *

Yes No
Legal Guardian Name *
Legal Guardian Phone Number *
Legal Guardian Email
example@example.com
Legal Guardian Address *

Street Address

Street Address Line 2

City State

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

Present Housing Situation: *

Live with Spouse Live with Parents Live with a relative Live with friends Incarcerated Treatment Facility Homeless Live alone

Education
Have you received a High School Diploma? *

Yes No
Have you received your GED? *

Yes No
What is the highest grade you have completed?
Have you attended College? *

Yes No
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 Member Friend
Emergency Contact Name *

First Name Last Name
Emergency Contact Address *

Street Address

Street Address Line 2

City State

Zip Code
Emergency Contact Home Phone Number

Area Code Phone Number
Emergency Contact Cell Phone Number *

Area Code Phone Number
Emergency Contact Email
example@example.com

Secondary Emergency Contact
Please select all that apply *

Family Member Friend
Emergency Contact Name *

First Name Last Name
Emergency Contact Address *

Street Address

Street Address Line 2

City State

Zip Code
Emergency Contact Home Phone Number

Area Code Phone Number
Emergency Contact Cell Phone Number *

Area Code Phone Number
Emergency Contact Email
example@example.com

Family Information
Mother's Name *

First Name Last Name
Mother's Address *

Street Address

Street Address Line 2

City State

Zip Code
Mother's Home Phone Number

Area Code Phone Number
Mother's Cell Phone Number *

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

First Name Last Name
Father's Address *

Street Address

Street Address Line 2

City State

Zip Code
Father's Home Phone Number

Area Code Phone Number
Father's Cell Phone Number *

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

First Name Last Name
Spouse's Address *

Street Address

Street Address Line 2

City State

Zip Code
Spouse's Home Phone Number

Area Code Phone Number
Spouse's Cell Phone Number *

Area Code Phone Number
Spouse's Email
example@example.com

Employment History

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

Month Day Year
Date
Ending Date *

Month Day Year
Date
Position *
Reason for leaving *
Company Name - Job 2 *
Starting Date *

Month Day Year
Date
Ending Date *

Month Day Year
Date
Position *
Reason for leaving *
Company Name - Job 3 *
Starting Date *

Month Day Year
Date
Ending Date *

Month Day Year
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

City State

Zip Code
Pastor's Name

First Name Last Name
Church Phone Number

Area Code Phone 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. *

Yes No
Medication 1:
Dosage
Medication 2:
Dosage
Medication 3:
Dosage
Medical Doctor *

First Name Last Name
Clinic Name *
Clinic Address *

Street Address

Street Address Line 2

City State

Zip Code
Clinic Phone Number *

Area Code Phone Number
Do you have a Mental Health Provider? *

Yes No
Mental Health Provider Name *

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

Street Address

Street Address Line 2

City State

Zip Code
Mental Health Provider Phone Number *

Area Code Phone Number

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

Yes No
Longest period of sobriety? *
Please list your previous/current treatment program(s) including the city where attended. *
Contact person at last treatment program? *

First Name Last Name
Phone Number *

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

Yes No
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.
Patient's Full Name *
Signature *

Clear
Date *

Month Day Year
Enter the message as it's shown *
Should be Empty:

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