Housing Application

Housing Program Application
Name of person applying to The Oaks Ministry Program*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email
example@example.com
Current phone number where you can be reached:*
Please enter a valid phone number.Format: (000) 000-0000.
Race
Ethnicity
How did you hear about The Oaks Ministry?*
Name of current inpatient Program/Facility or Housing situation.*
Example: I am in xx Rehabilitation Center or I am staying with my sister
Name of Referral or Contact person:

First NameLast Name
MarriedSingleDivorcedOther
YesNo
Who currently has custody of your minor children?
YesNo
If so, what rendered you homeless?
YesNo
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Health
YesNo
If yes, please list company name and Policy Number:
YesNo
YesNo
If yes, list the condition(s) you are being treated for and the name and contact information of the doctor(s) providing treatment:*
If yes, what medicine/s are you currently taking? List medicine, dosage, prescribing doctor and doctor's contact information:*
YesNo
Mental Health
YesNo
If yes, list the condition(s) you are being treated for and the name and contact information of the doctor(s) providing treatment:*
YesNo
If yes, what medicines, if any, are you currently on? List medicine, dosage, prescribing doctor and doctor's contact information:*
Employment

The Oaks Ministry Policy includes a 30 day resting period where residents are not permitted to work.
YesNo
If yes, where?
Number of hours worked per week?
Net pay (bring home) per week ?
YesNo
Financial
YesNo
Recovery
YesNo
If yes, which addiction(s) do you struggle with:
Names, dates, and length of stay at previous recovery programs:*
How long have you been sober from drugs/alcohol?*
NoYes
Sponsor Name

First NameLast Name
Sponsor Phone Number (We reserve the right to contact your sponsor)
Please enter a valid phone number.Format: (000) 000-0000.
Transportation
YesNo
YesNo
YesNo
YesNo
Education
YesNo
Legal
YesNo
YesNo
YesNo
If incarcerated, what was the charge?
YesNo
Probation/Parole Officer's name

First NameLast Name
Probation/Parole Officer's Contact Info.
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
List all current/pending charges below
Spiritual
YesNo
YesNo
What do you hope to accomplish by participating in The Oaks Ministry Program?*
What is the best time for you to be interviewed?*
What is the best way to contact you?*
I, the named below individual, desire to enter The Oaks Ministry Residential Program.

First NameLast Name
The Oaks Ministry Residential Program is a Christian Discipleship Training Program. I have made a commitment to Jesus Christ, or I am willing to consider the possibility of doing so. People who enter The Oaks Ministry Residential Program may have had histories including, but not necessarily limited to, drug and alcohol abuse, and/or mental or emotional problems. The Oaks Ministry Residential Program is not licensed by the State of Pennsylvania as a Drug and Alcohol Treatment Program or as a Mental Health Facility. The program offered by the Oaks Ministry team consists of Bible-based teaching with spiritual emphasis.

Any false statements or answers on this application may be subject to denial or admission into, or, dismissal from The Oaks Ministry Residential Program.
Signature*

Clear
Completed applications may also be submitted to:

The Oaks Ministry Housing Program

P.O. Box 29 Oxford PA 19363
YesNo
Medicine name*
Dosage*
Prescribing doctor*
Doctor's contact information*
Should be Empty:

Housing Program Application

Health

Mental Health

Employment

Financial

Recovery

Transportation

Education

Legal

Spiritual