Men's Faith Home Application

Men's Faith Home Ministry

INTAKE APPLICATION
Date

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Personal Information
Social Security No.*
###-##-####
Age*
Date of Birth*

MonthDayYear
Date
Sex

Male
Driver License / ID No.
State Issued
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Address (if less than one year at current address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Marital Background
Marital Status

SingleMarriedSeparatedDivorcedWidower
If Married, provide Spouse information

Name   First Name   Last Name

Phone No.   Area Code   Phone Number

Current Address   Street Address   Address Line 2   City   State   Zip

Occupation      Employer

Employer Phone No.   Area Code   Phone Number
Have you been previously married?

YesNo
If previously married, list all former spouses. Please include Name, Date Married and Status of Marriage.
Do you have children?

YesNo
If you have children, list all children. Please include Name of Child, Sex, Age and Whom they are living with:
Employment Background
Are you presently employed?   Yes   No

Employer     Phone No.   Area Code   Phone Number

Address   Street Address   Address Line 2   City   State   Zip

How long?

What is your preferred occupation?
List any jobs you have had within the past five years from the most recent. Please Include Employer Name, Date, Position and Reason(s) for leaving:
Family Background
Father's Name   First Name   Last Name

Address   Street Address   Address Line 2   City   State   Zip

Phone No.   Area Code   Phone Number

Age      Living?   Yes   No
If not living, when deceased?   Date
Briefly describe your father and your relationship with him:
Mother's Name   First Name   Last Name

Address   Street Address   Address Line 2   City   State   Zip

Phone No.   Area Code   Phone Number

Age      Living?   Yes   No
If not living, when deceased?   Date
Briefly describe your mother and your relationship with her:
Military Service Background
Branch

Entrance Date   Date   Discharge Date   Date

Highest rank obtained?
Education Background
List schools attended (high school and/or military). Please include Name of School, Location, Dates Attended and Grade Completed:
Did you receive discipline for problems at school?

YesNo
If so, what, when and why:
Did you receive your high school diploma or GED?

YesNo
If so, what year?
If not, why?
List colleges or trade schools you have attended. Please include Name of School, Location, Dates Attended and Grade Completed:
Medical / Physical / Well-Being Background
Select any of the following symptoms or conditions you have had:

Blurred VisionBlackoutsDizzy SpellsVomited BloodStomach PainsShortness of BreathDiabetesTuberculosisBruise EasilyKidney InfectionVenereal DiseaseAIDSSinus InfectionsDouble VisionMigraine HeadachesHead InjuriesBlood in StoolUlcersJaundiceHeart AttackSwollen AnklesSevere CoughingUrine InfectionAllergiesBlood TransfusionsFrequent ColdsHeadachesSeizuresLoss of ConsciousnessBlood in UrineHepatitisChest PainsHearing LossPneumoniaChemical BalanceBack PainWeakness in Arms/LegsBroken BonesLoss of an Eye
Has anyone in your family (parents, brothers, sisters, grandparents, aunts, uncles, cousins, children) had any of the following:

Kidney DiseaseTumorsEpilepsyHeart DiseaseDiabetesNervous DisordersCancerMental Illness
Do you have any medical problems now that would require a doctor's care?

YesNo
If so, what?
Do you have any appointments now pending with any type of doctor?

YesNo
If so, what?
List any serious illness(es) you have had in the past five years:
Have you been hospitalized for health-reasons within the past five years?

YesNo
If so, list the hospital, city, dates and diagnosis of when you were hospitalized:
Name and Address of your physician:
Are you on any medication at the present time?

YesNo
If so, describe and what for:
Have you had any previous pastoral, psychological or psychiatric counseling/treatment for mental health or have you ever been "institutionalized" for any problem?

YesNo
If so, list what type of counseling/treatment you had, with whom, when and explain briefly for what problem you sought help for:
Have you or anyone in your immediate family or parental family ever threatened or attempted suicide?

YesNo
If so, explain briefly:
Provide the following information if applicable:
Drug/Alcohol History - List the type of drug, the age you first used it, how long you used it, the way you used it and how frequently you used it. Be specific:
Past Detox Treatment - List the Name of Center, Location and Dates Attended:
Past Programs - List the Name of Program or Support Group, Location and Dates Attended:
Select any of the following symptoms or conditions you have had in the past or are experiencing now, NOT related to symptoms of drug use:

Insomnia (can't sleep)Weight Loss/GainAppetite ChangesDrug UsageAlcohol UsageCigarette UsageTobacco UsageMood Highs/LowsIrritabilityExcessive WorryingCrying SpellsPhobias/FearsHallucinationsHearing Unseen VoicesConfusionLow Self EsteemDifficulty ConcentratingFrequent Loss of TemperActing Out ViolenceCompulsionDepressionExtreme NervousnessBed Wetting Past Age SixFingernail BitingBlaming Others FrequentlyLack of MotivationOvereatingIndecisivenessLack of Sexual AwarenessSpiritual ConfusionExtreme LonelinessFrequent AccidentsLoss of MemoryThoughts of SuicideFantasizingDaydreamingInability to Comprehend ReadingInability to Comprehend MathInability to Express Self
Have you ever been charged or convicted as a sex offernder?

YesNo
Are you or have you been homosexual?

YesNo
Have you had homosexual experiences before?

YesNo
NOTE: These behaviors cannot continue while being a part of the Faith Home.
Jail / Prison Background
Have you ever been arrested?

YesNo
If so, for what reason, when was it and what was the outcome?
Have you ever served time in prison?

YesNo
If so, list Name of Facility, Location, Dates and Reason:
Are you currently on probation?

YesNo
If so, list Name of probation officer and Phone number:
Are you in violation now?

YesNo
Are you on parole?

YesNo
If so, list Name of parole office and Phone number:
For what reason are on probation and/or parole?
List Name of public defender and Phone number:
Spiritual Background
Have you been attending church?

YesNo
If so, what church?
How often do you attend?

RegularlyFrequentlyOccasionallyInfrequently
Check any of the following you believe in:

His Son, JesusHellForgiveness of SinsHealingsSpeaking in TonguesThere is a heavenly reward for the righteousGod loves youThe Holy SpiritSalvationTithingMiraclesSatanJesus loves youHeavenBaptism of the Holy SpiritOfferingsLaying on of HandsDemonic ForcesGod wants you to be happySatan comes to steal, kill and destroyJesus came to give us abundant life here on this earth
Do you consider yourself to be a "born again Christian"?

YesNo
Why or Why Not?
What religion are you?
What is your natural father's religion?
Does he practice it?

YesNo
What is your natural mother's religion?
Does she practice it?

YesNo
What is your natural stepfather's religion?
Does he practice it?

YesNo
What is your natural stepmother's religion?
Does she practice it?

YesNo
Any comments you would like to share on the above referenced subject?
General Information
How were you referred to the Lighthouse Gospel Mission, Inc. & Faith Home?
Why did you come to the Lighthouse Gospel Mission, Inc. & Faith Home?
In case of emergency please contact - List Contact Name, Address, Phone Number, and Relationship:
Should be Empty:

Men's Faith Home Ministry