Valley Rescue Mission

Valley Rescue Mission

Women and Children's Shelter Program Application
Name*

First NameLast Name
Current or Last Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Age*
Birth Date*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Height*
Weight*
Hair*
Eyes*
Referred By*

Do you know or are you acquainted with anyone connected to Valley Rescue Mission?*
Why are you applying to a Shelter Program at this time?*
What are your immediate needs?*
What are your present goals?*
What are your strengths?*
What are your weaknesses?*

List any Children that will be residing with you and DOB*
How will you provide child care while working?*
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Address*
Emergency Contact Phone Number*
Please enter a valid phone number.
Do you have family in Muscogee County or the immediate area?*

List drugs you have tried*

	Amount/How Often Used	Date Started	Date of Last Use
Cocaine/Crack
Marijuana
Heroin
Alcohol
Nicotine
Prescription Drugs
Methamphetamines
Kratom/Spice
Fentanyl
Other

Drug of Choice*
Age of first use*
Longest period of sobriety*
List any previous recovery programs and dates*
Do you smoke?*
Are you willing to quit?*
Have you ever sought treatment for an eating disorder?*
If yes, please explain*
Have you ever attempted suicide?*
Do you have current suicidal thoughts?*
Have you been hospitalized for emotional or nervous reasons?*
If yes, please explain and give dates.*
Have you every been in Therapy?*
If yes, please explain and give dates.*
If so, were medications prescribed?*
If yes, please list medications, and reasons for taking.*

Have you ever experienced any of the following types of abuse?*

	Childhood	Adult	None
Physical Abuse
Emotional or Verbal Abuse
Sexual Abuse

Are you presently in contact with anyone who is/was abusive to you?*
When was last contact with abuser?*
Please describe any family or self psychiatric history*
Have you ever been arrested?*
Please explain prior arrests.*
Are you a registered sex offender or charged with a violent crime?*
Do you have any pending charges?*
Please list and explain.*
Please list any charges and applicable counties.*
Are you on probation/parole?*
If yes, what state?*
List name and phone number of probation officer.*
Are you currently taking medications?*
If yes, list all medication currently prescribed.*
Have you had any major/minor surgery in the last five years?*
Are you currently under medical supervision?*
If yes, please explain.*
Please list Physician, phone number and address*

What is the highest level of education completed?*
Are you a Veteran?*
Are you employed?*
If not, please list last job and dates of employment.*
Last residence.*
Ever received housing assistance?*
Do you owe the Housing Authority money?*
Are you presently homeless?*
Are you currently receiving Medicare/Medicaid? *
Are you currently receiving Disability/ SSI?*
If yes, how much?*
Are you receiving any other government aid?*
Are you on food stamps/EBT?*
Do you receive CAPS?*
Do you receive Child support?
If selected for residence in this program, is there anything that we should know about you that would hinder your ability to sweep, mop, lift, mow, or do normal household chores?*
Please give a little information about yourself, your current situation and why you feel this is the right program for you.*
NOTE: This center is not a medical or psychiatric facility: therefore, prospective clients must be medically, as well as, psychiatrically cleared prior to admission. The requested medical information within this application for consideration of admission form is vitally important and is required before a decision can rendered as to the appropriateness of our facility for prospective clients. If mental health evaluation / documentation is requested, that also must be received before a final decision can be made regarding placement in the Program. If, within 30 days of admission, it is noted that the client is inappropriate due to medical or psychiatric reasons about which we were inadequately informed, this facility reserves the right to refer the client to another facility or back to the referring agency.
Signature Name*
Should be Empty:

Biosychosocial Assesment

Are you currently experiencing the following?