Nazareth Man House Application - Foresight For-Givers Foundation, Inc.

Dental:
When was your last dental examination & treatment?
List any diagnosed dental disorder:
Do you wear

DenturesPartials
Vision:
Date of last eye exam?
Name any diagnosed condition?
Do you wear?

Eye GlassesContact Lenses

Mental Health:
List any diagnosed mental disorder(s):
Do you take medication?

YesNo
If so, name prescription(s)? Daily dosage? Frequency?
When is the last time you were in treatment? Year?
Where:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Doctor:

PrefixFirst NameMiddle NameLast NameSuffix
Duration of treatment:
Have you ever been suicidal?

YesNo
Have you ever been treated for suicide?

YesNo
When?
Where?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctor/Facility?
Have you ever had self-mutilation issues?

YesNo
When?
Where?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctor/Facility:

Job History:

List your first job to your most recent (Do not include prison jobs).:
1. Company's Name?
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of employment from:
Started & Ended
Job Description:
2. Company's Name?
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of employment from:
Started & Ended
Job Description:
3. Company's Name?
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of employment from:
Started & Ended
Job Description:

Are you responsible for child support?

YesNo
Mother of child(ren):
Amount owed:
Are your payments current?

YesNo
Amount in arrears:
Are you repaying educational loans?

YesNo
Amount owed:
Amount of payment
Are payments current:

YesNo
Explain any other debts you have:

Hobbies/Favorite Things:
If you had someone planning social events and things you enjoyed doing for fun and relaxation, what type of things would be on your list?
What hobbies do you have?
What type of entertainment do you enjoy?
What was the last movie you watched?
What type of music do you like?
What is your favorite song & artist?
How do you like to spend your leisure time?
What type of books/magazines do you prefer reading?
What was the title of the last book you read?
What places do you like to visit?

Essay:
Please write at length on a separate sheet of paper for each of the following questions:
• What are your life goals?
• What do you want to be?
• What do you want to accomplish?
• What do you need to do or become to consider yourself successful?
• Do you think you can reach your goals?
• Are you willing to do whatever it takes to reach your goals?
• What do you need help with?
• If you get that help can you get to where you want to be?
• Who will you need to reach your goal?
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FORESIGHT FOR-GIVERS FOUNDATION, INC.
THE NAZARETH MAN HOUSE

Biographical Information:

Family Information:

Father

Mother

Brother

Brother

Sister

Sister

Wife

Children:

Children:

Children:

Health Status

Medical:

Dental:

Vision:

Mental Health:

Educational Background:

Job History:

Financial History:

Social History:

Criminal History:

Hobbies/Favorite Things:

Faith History:

Essay:

FORESIGHT FOR-GIVERS FOUNDATION, INC. THE NAZARETH MAN HOUSE

Biographical Information:

Family Information:

Father

Mother

Brother

Brother

Sister

Sister

Wife

Children:

Children:

Children:

Health Status

Medical:

Dental:

Vision:

Mental Health:

Educational Background:

Job History:

Financial History:

Social History:

Criminal History:

Hobbies/Favorite Things:

Faith History:

Essay:

FORESIGHT FOR-GIVERS FOUNDATION, INC.
THE NAZARETH MAN HOUSE