REDEMPTION CITY APPLICATION FOR ENTRY TO THE LIGHTHOUSE
Name
*
First Name
Last Name
Birthdate
*
/
Month
/
Day
Year
Date
SS #
*
Former Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Shelter
Shelter Name
Or
Non-Housing (car, street, woods, etc.)
DOC
Phone
Email
example@example.com
Veteran:
*
Yes
No
If yes, what branch?
Relationship Status
*
Single
Married
Divorced
Children?
*
Yes
No
Ethnicity
*
Emergency Contact
Phone
Relationship
Emergency Contact
Phone
Relationship
Referring Agency
*
Agency Name or N/A
Case Manager (if applicable)
Phone
Do you have a license?
*
Yes
No
If yes, license number
If no do you need help obtaining a license or State ID?
*
Yes
No
Do you have a car?
*
Yes
No
If yes, tag number
Are you able to work without limitations?
*
Yes
No
If no, what are your limitations?
Are you currently working?
*
Yes
No
If yes, workplace?
Work Schedule?
Length of current employment?
Pay/hr?
Are you currently receiving disability?
*
Yes
No
Disability amount
Are you currently in the process of trying to receive disability?
*
Yes
No
Do you receive any of the following?
*
General Public Assistance
Child Support
VA Benefits
Medicaid
Medicare
Foodstamps
None
Other (please specify)
Are you currently on probation?
*
Yes
No
If yes, officer’s name and phone
Are you on parole?
*
Yes
No
If yes, officer’s name and phone
Do you currently have any outstanding criminal issues?
*
Yes
No
If yes, please explain
Do you have any upcoming legal obligations? (court cases, etc.)
*
Yes
No
If yes, please explain
Outstanding warrants?
*
Yes
No
If yes, what are the nature of the warrants?
Have you ever been convicted of any violent crimes?
*
Yes
No
Do you have a history of addiction to illegal and/or prescribed substances?
*
Yes
No
If yes, please list substance(s).
Do you have a history of alcoholism?
*
Yes
No
When is the last time that you used drugs?
*
MM/DD/YYYY or N/A
When is the last time that you used alcohol?
*
MM/DD/YYYY or N/A
Have you completed any drug treatments programs?
*
Yes
No
Program Name
Are you in the process of completing a treatment program?
*
Yes
No
Program Name
Are you currently on MAT (medically assisted treatment)?
*
Yes
No
Have you been diagnosed with a mental health disorder?
*
Yes
No
Are you currently seeing a psychiatrist or therapist?
*
Yes
No
If yes, where?
Do you feel you need help obtaining mental health services or diagnosis?
*
Yes
No
Please upload a copy of your photo ID
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