Still Waters Application

Still Waters is a faith-based transitional home and program for women who desire to make lasting changes.

Thank you for your interest in Still Waters. If approved for the program we will work one-on-one with you to help you meet your goals. The program is a minimum commitment of 90 days. During that time you will be required to find a job, volunteer, go to church, and attend Celebrate Recovery. A background check and a drug test must be completed before entry.

Name

First NameLast Name

Current or Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

How did you hear about Still Waters?

Education: (check all that apply)

Military Veteran

Are you currently homeless?

Reason for needing shelter?

Within the last year how long have you been without housing?

Where did you sleep last night?

Last Job? How long did you work there?

Reason for leaving last job?

Have you ever been diagnosed with any of the following: (check all that apply)

Are you pregnant?

Do you currently:

Have you ever abused drugs or alcohol? If yes please explain.

Have you ever been in a treatment facility?

Have you ever been arrested? If yes, please explain.

Have you ever been convicted of a crime? If yes, please explain.

Have you ever been incarcerated? If yes, please explain.

Religious Affiliation:

Do you attend church?

Relationship Status

How many children have you given birth to?

List all children who live with you and their ages:

Do you have a support person in your life? If yes list name(s) and relationship.

Emergency Contact:

Name

Street Address

CityState / Province

Postal / Zip Code

Emergency Contact Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Why do you want to be in Still Waters?