Preliminary Program Application

Name

First NameLast Name

Email

example@example.com

Bethlehem House is dedicated to equipping and motivating individuals to become purposeful community members. Listed below are key components of the Bethlehem House Program. Please note whether you are willing to participate in each area.

Date

Do you agree to find and maintain full time employment?

YesNo

Are you currently receiving or in the process of applying for Social Security Disability (SSDI) or Supplemental Security Income (SSI)? This information helps us better understand how to support you and may impact eligibility for certain services or benefits. Your response is confidential

YesNoPrefer not to answer

Participation in the Bethlehem House Money Management Program is mandatory. Do you agree to participate if this program?

YesNo

Do you agree to complete weekly House Hours (in addition to your assigned weekly chore) until you are employed? House Hours include activities that support the household or contribute to your personal growth and recovery, such as attending classes, volunteering, or working on physical/mental wellness.

YesNo

Do you agree to participate in counseling sessions, educational courses, and/or addiction recovery classes as assigned?

YesNo

Do you agree to continue to work on and maintain your sobriety, if applicable?

YesNo

Do you agree to commit to and complete the Bethlehem House Transitional Housing Program, which can last anywhere from 6 months to 2 years depending on individual progress and goals?

YesNo

Do you have any prior convictions or pending charges related to violent or sexual charges?

YesNo