Damascus House for Women Application
Please fill out every field and ensure you sign all the proper fields
Are you a male or a female? IF YOU ARE A MALE THIS IS THE WRONG FORM. Please go back out to the main website and click on the "men's" tab.
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MALE
FEMALE
Name
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First Name
Last Name
Middle Initial
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Cell Phone Number
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Please enter a valid phone number.
Home Phone Number (if applicable)
Please enter a valid phone number.
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Driver's License Number
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Is your driver's license suspended?
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Yes
No
Explain:
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Date of Birth
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-
Month
-
Day
Year
Date
Age
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Weight
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Height
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Hair Color
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Eye Color
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Instagram Handle
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Facebook Account
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Marital Status
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Please Select
Single
Dating
Engaged
Married
Separated
Divorced
Serious Relationship
Lesbian/Transgender
MARRIAGE AND FAMILY INFORMATION
Name of Spouse/Significant Other
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First Name
Last Name
Spouse/Significant Other Phone Number
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Please enter a valid phone number.
Spouse's/Significant Other Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Spouse's/Significant Other Occupation
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Spouse's/Significant Other Age
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Do you have children?
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Yes
No
INFORMATION ABOUT CHILDREN
Please fill in all fields for each of your children
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Name
Age
DOB
Male/Female
Custody
Child 1
Child 2
Child 3
Child 4
What arrangements are being made for your children while you are at The Damascus House for Women?
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Education (last year completed):
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Other training (list the type and years completed):
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Who referred you to The Damascus House For Women?
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HEALTH INFORMATION
Rate your health:
Very Good
Good
Average
Declining
Other
Explain
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Weight Changes:
Lost
Gained
Neither
Do you consider your eating habits normal?
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Yes
No
Explain
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Are you on a special diet?
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Yes
No
Explain
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Do you eat meat?
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Yes
No
Do you have any medically verifiable food allergies?
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Yes
No
Explain
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Do you have any medically verifiable disabilities?
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Yes
No
Explain
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Date of last medical examination:
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List an physical limitation you may have as indicated by a physician
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Have you had any past surgeries or medical hospitalizations?
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Yes
No
List all past surgeries or medical hospitalizations including reason and date:
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Do you take any prescription medications?
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Yes
No
Prescription History
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Name
Dosage
For What Reason
How long
Prescription 1
Prescription 2
Prescription 3
Prescription 4
Prescription 5
Prescription 6
Prescription 7
Prescription 8
Which of the following substances have you experimented with, past or current?
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Alcohol
Crank
Crystal Meth
Marijuana
Spice
Hallucinogenic (Acid, LSD, etc)
Amphetamines (Uppers)
Barbiturates (Downers)
Meth Amphetamines
Morphine
Opiates
Heroin
Cocaine
Inhalants
Crack
Tabacco
Ecstacy
Fentanyl
Other
Preferred Drugs:
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Name of Drug
Frequency of Use
Date of Last Use
Drug Name
Drug Name
Drug Name
Drug Name
Drug Name
Drug Name
Drug Name
Have you ever experienced a life-altering, traumatic event, that still affects you?
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Yes
No
Explain
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Have you recently suffered the loss of someone close to you?
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Yes
No
Explain
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Have you ever been tested for an STD?
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Yes
No
Please provide month and year of when you were tested
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What was the result of your STD test?
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Have you ever been tested for HEP-C?
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Yes
No
Please provide month and year of when you were tested
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What was the result of your HEP-C test?
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Have you ever been tested for HIV/AIDS
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Yes
No
Please provide month and year of when you were tested
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What was the result of your HIV/AIDS test?
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Are you currently pregnant?
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Yes
No
Do you have any learning disabilities (reading or writing)?
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Yes
No
Explain
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SPIRITUAL BACKGROUND
Do you believe in God?
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Yes
No
Uncertain
Are you saved?
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Yes
No
Not sure what you mean
PERSONALITY INFORMATION
Have you ever had any psychotherapy or counseling before?
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Yes
No
Exlpain
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If yes, list counselor or therapist and dates you were in counseling:
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What was the outcome?
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Have you ever been in a drug or alcohol program?
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Yes
No
Recovery Program History
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Date of Entry
Program Name
City/State
Reason for Leaving
Date of Discharge
Facility 1
Facility 2
Facility 3
Facility 4
CHECK ANY OF THE FOLLOWING WORDS WHICH BEST DESCRIBE YOU NOW:
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Active
Ambitious
Self-confident
Persistent
Nervous
Hardworking
Impatient
Impulsive
Calm
Moody
Often-blue
Excitable
Imaginative
Serious
Easy-going
Shy
Good natured
Introvert
Extrovert
Likeable
Leader
Quiet
Submissive
Lonely
Self-Conscience
Sensitive
Have you ever felt like people were watching you?
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Yes
No
Explain
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Have you ever had hallucinations?
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Yes
No
Explain
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Are you afraid of being in a car?
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Yes
No
Explain
Do you have problems sleeping?
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Yes
No
Explain
Have you ever tried to commit suicide?
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Yes
No
Why?
Have you ever received psychiatric care or been in a psychiatric hospital?
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Yes
No
Psychiatric Hospitalization History
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Date of Entry
Program Name
City/State
Reason for Leaving
Date of Discharge
Facility
1
Facility 2
Facility 3
Facility 4
Are you on any type of government or financial assistance, such as Welfare, SNAP or SSI?
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Yes
No
What type?
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Is there any other information we should know?
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I, undersigned, agree that all information is correct:
Signature
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Date
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-
Month
-
Day
Year
Date
Submit
Should be Empty: