• APPLICATION FOR ADMISSION - Women -

    APPLICATION FOR ADMISSION - Women -

    7200 DeSiard St - Monroe, LA 71203 | 318-343-4445

  • Please answer all questions completely. All information is kept confidential.

  • Format: (000) 000-0000.
  • Is it safe to text or leave a message?*
  • If you have a DL, is it suspended?*
  • Are you a US Citizen?*
  • Marital Status*
  • Rows
  • Do you attend church?*

  • Background Information

    Please answer questions to the best of your knowledge.
  • Have you ever received counseling?*
  • Do you think you could benefit from counseling?*
  • Have you ever had a psychological evaluation?*
  • Do you use drugs or alcohol?*
  • Do you use tobacco products?*
  • Have you ever been physically abused?*
  • Have you ever been convicted of a crime? (Felony/Misdemeanor)*
  • Do you have any pending criminal charges against you?*
  • Are you on probation?*
  • Are you in any legal trouble? (not including traffic tickets, etc.)*
  • Have you ever been a past resident in any program at LBCHFM?*

  • Parent and Child(ren) Status

    Please answer all questions to the best of your knowledge.
  • Are you pregnant?*
  • Are you seeing a doctor?*
  • Are you or have you been involved with DCFS/CPS?*

  • References

  • Rows

  • Education

  • Work History

  • Rows

  • Transportation

  • Do you have a car?*

  • HomePlace Application Agreement

  • The information contained in the application is correct to the best of my knowledge. I understand that making false statements or being untruthful at any time will result in termination of LBCHFM services.

  • Should be Empty: