Still Waters Housing Application

Children
Do you have children currently in your custody?*

YesNo
Treasure House is only able to consider applicants who have children 3 years and younger at the time of intake.
How old are your children?*
Are you currently pregnant?*

YesNo
Due Date:
Do you have children who do not live with you?

YesNo
Do you have an open or ongoing custody case?

YesNo
How old are your children who do not live with you?

Current Circumstances
What do you feel is the cause of your present difficulties?*
Reflecting on your behaviors, what has been problematic for you and why?*
What are your areas of growth you hope to address?*
What does a typical day look like for you?*
How would you define success throughout your time as a resident in this program? *
What support do you need to help you overcome your present barriers? *

Employment
Are you able to work 15-40 hours/week?*

YesNo
If no, please explain:
Are you currently employed?*

YesNo
Are you willing to keep your working hours between 5am and 5pm in order to meet program requirements?

YesNo

Other Sources of Income
Do your receive monthly assistance from TANF?*

YesNo
How much do you receive per month from TANF?
Do your receive monthly assistance from SSI/SSDI?*

YesNo
How much do you receive per month from SSI/SSDI?
Do you receive unemployment income?*

YesNo
How much do you receive per month from unemployment income?
Please list any other monthly financial assistance here:
List monthly amount and where it's coming from.

Legal History
Have you ever been convicted of a crime?*

YesNo
While we do accept people with criminal histories, including felonies, City Ordinance 565.28.1, prohibits us from accepting those who are currently serving probation or parole for a crime against a person and those who have an outstanding warrant.
Please list out current charges.*
Are you currently on parole or probation?*

YesNo
Do you have any outstanding warrants?*

YesNo

Drug & Alcohol History
If applicable, please list your substance(s) of choice.*
Do you believe you have an addiction?*

YesNo
What is the date of your last use?

MonthDayYear
Date
What is your longest stretch of sobriety?
Do you believe you have other addictions (eating, unhealthy relationships, spending, etc.)?*

YesNo
Please specify:
Are you open to participating in a recovery group, meeting or program?*

YesNo
List any past or drug/alcohol treatments or sober living below:

Sex Industry History
Have you ever exchanged sex for money, food, drugs, housing, etc.?*

YesNo
Have you ever been sexually exploited? - Sexual exploitations is defined as an actual or attempted abuse of someone's position of vulnerability (such as a person depending on another for survival, food rations, transport or other services), differential power or trust, to obtain sexual favors, including but not only, by offering money or other social, economic or political advantages. It includes trafficking and prostitution.*

YesNo

Physical Health History
Do you have any disabilities or medical conditions that keep you from working or limit the type of work you do?*

YesNo
Please explain.*
Please list out any medical conditions/diagnoses/recent/upcoming surgeries or health problems that we should know about. *
Are you able to use stairs?*

YesNo

Family History
Have you ever lived in a group home or foster care?*

YesNo
Previous generations of my family have been involved with: (check all that apply)*

HomelessnessAddictionsDomestic ViolenceTANFMental Health TreatmentN/AOther

Religious Beliefs
Are you open to exploring Christian spirituality as part of this program?*

YesNo
Do you have concerns about a Christian program? If so, what are your concerns?*

I attest that I have answered all questions accurately and honestly to the best of my recollection: (please sign below)*

Clear
Date*

References

3 References Required
I hereby release the below named organizations and/or persons from confidentiality for the purposes of discussing my treatment with the staff of Still Waters Housing, Open Door Ministries. *

Clear
Date*
Please list both personal and professional references below. Suggested refernces: probation or parole officers, case managers, mental health providers, counselors, psychiatrists, friends, family, or employers.
Name of Reference #1*
Phone Number*
Relationship to You*
How long have you known him or her?*
Which county/office do they work in? (If applicable)*
Name of Reference #2*
Phone Number*
Relationship to You*
How long have you known him or her?*
Which county/office do they work in? (If applicable)*
Name of Reference #3*
Phone Number*
Relationship to You*
How long have you known him or her?*
Which county/office do they work in? (If applicable)*
I also release the staff of Still Waters Housing from confidentiality for the purposes of discussing my treatment with the above named organizations and/or persons.*

Clear
Date*

Background Check
I authorize Open Door Ministries and/or its agents to make an independent investigation of my background, references, character, past employment, education, credit history, criminal or police records, and motor vehicle records including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my Application and/or obtaining other information which may be material to my qualifications for my acceptance now and, if applicable, during the tenure of my stay with Open Door Ministries. I release Open Door Ministries and/or its agents and any person or entity, which provides information pursuant to this authorization, form any and all liabilities, claims or law suits in regards to the information obtained form any and all of the above referenced sources used.*

Clear
Date*
Should be Empty:

	Currently Experiencing (within the Previous 7 Days)	Have Experienced in the Past
Self Harm
Domestic Violence
Recurring Homelessness
Loss of a Child
Eating Disorder
Paranoia
Social Anxiety
Sexual Abuse
Uncontrolled Anger
Codependency

	Currently Experiencing (within the Previous 7 Days)	Have Experienced in the Past
Cult Involvement
Homicidal Thoughts
Chronic Pain/Illness
Loss and Grief
Mania
Obsessive Behavior
Paralysis
Physical Abuse
Prescription Abuse
Suicidal Thoughts or Attempt

	Currently Experiencing (within the Previous 7 Days)	Have Experienced in the Past
Fear for Life
Memory Loss
Verbal Abuse
Pornography
Rape
Same Sex Attraction
Sexual Addiction
Poor Time Management
Missing Work
Hallucinations (Visual or Auditory)
Issues with Authority
Avoiding Responsibility

Children