Haven Homes for Women Resident Application Form

Resident Application

This application MUST be filled out completely and honestly. "Surprises" in your potential interview or, if accepted, may interfere with your acceptance and/or residency.
Name*

First NameLast Name
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Must be a valid working phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Social Security Number*
Do you have a Social Security card in your possession?

YesNo
Driver's License/State ID Number *
Do you have a current Driver's License or State Issued ID in your possession?

YesNo
Highest Level of Education*

Some High SchoolHigh School DiplomaGEDSome College (no degree)College Degree (Associates, Bachelors, etc.)Other
Marital Status

SingleMarriedDivorcedWidowedNever Married
Veteran Status*
Do you have children?*

YesNo
If yes, do your children live with you?*

YesNoNot applicable
Do you have an open CPS case?*

YesNoNot applicableType option 4
Are you seeking to get your children back?*

YesNoNot applicable
Do you owe or pay child support?*

YesNo
Do you receive a check of any kind?*

YesNo
If yes, what kind of check do your receive?*
Have you ever been incarcerated?*

YesNo
If yes, why and when were you incarcerated? If no, write N/A.**
Do you have any pending legal issues or court dates?*

YesNo
If yes, please give specific details. If no, write N/A.*
Are you on probation or parole?*

YesNo
If yes, give specific details: including charge, state, county, probation/parole officer name and number. If no, write N/A.*
Are you a convicted sex-offender?*

YesNo
Have you ever been prescribed medications for a mental health disorder?*

YesNo
If yes, what is your mental health diagnosis? If no, write N/A.*
If yes, list the mental health medications currently prescribed. If no, write N/A.*
List all medications you are currently taking for mental health. *
Have you ever had a seizure?

YesNo
If yes, how long has it been since you had one? When was the last time you had a seizure?
What was the cause of your seizure? drugs, alcohol, name of medical condition, unknown cause?
List all surgeries you have ever had.
Do you have a medical condition that requires a doctor's care and/or medication?*

YesNo
If yes, what is your medical diagnosis? If no, write N/A.*
If yes, list medications prescribed for your medical condition. If no, write N/A.*
List all medications you are currently taking for any medical condition: prescription, over-the-counter, etc. *
Have you ever been in a recovery program/mission/rehab/mandated rehab?*

YesNo
If yes, list all recovery programs/missions/rehab/mandated rehabs you have been to, when you were there, and how long you stayed. If no, type N/A.*
What was your exact reason for leaving?*
What is your drug of choice?*

AlcoholMethamphetamineHeroineBenzodiazepineOther
What other drugs have you used or currently use? (Ex: Amphetamines, Adderall, Cocaine, Methadone, Oxy, Hydro, Fentanyl, Suboxone, Xanax, Valium, Klonipin, Marijuana.)*
What is the longest you have been clean?*

0-6 months7-9 months10-18 months19 months - multiple years
When was the last time you used and what did you use?*
Have you recently been through detox?*

YesNo
Do you use tobacco? (Tobacco is permitted but not provided.)*

YesNo
Write a paragraph on why you want to enter this program?*
List 5 goals you want to see accomplished by your graduation at Haven Homes for Women. *
What are your dreams for your future?*
Is there anything else that we need to know?*
What do you believe about God?*
Who do you say that Jesus is?*
How did you hear about us?*

Friend or FamilyCourt System (jail, probation or parole officer, judge, etc.)Social MediaOnline SearchOther
If you could choose when you enter the program, when would that be?*
Date of Signature*

MonthDayYear
Date
I certify that all the information that I have stated is true to the best of my knowledge. I also understand that a background check might be done and I may receive random drug testing and inspections while at Haven Homes for Women.*
Please verify that you are human*
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