Grace House Participant Application
This application helps us better understand your needs and determine eligibility for our program. All information shared will be kept secure and only used by Grace House Advantage LLC.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
*
/
Month
/
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Are you able to live independently without daily assistance? Included but not limited to (cooking, cleaning, hygiene, etc.)
*
Yes
No
If no, please describe assistance that's needed.
Do you have a case manager?
*
Yes
No
If yes, please provide their email address and phone number.
Emergency Contact
Current living situation?
*
Living with family
Hospital
Jail/Prison
Shared housing
Shelter
Homeless
Other
Do you have any disabilities or special needs?
*
Yes
No
If yes, please explain.
Do you have mental health conditions?
*
Yes
No
If yes, please describe.
Do you have any mobility concerns?
*
Yes
No
If yes, please describe.
Do you take any medications?
*
Yes
No
If yes, please describe.
Do you have any history of substance abuse?
*
Yes
No
If yes, when was the last time you used? What is your substance of choice?.
Have you been convicted as a sex offender?
*
Yes
No
If yes, please explain when you were convicted.
Are you currently on probation or parole?
*
Yes
No
Are you currently receiving any of the following on a monthly basis? (check all that apply)
*
SSI
SSDI
Pension
Employed
Assistance from a charity
VA benefits
Other
Please describe and provide income amounts.
*
Do you receive EBT (food stamps)?
*
Yes
No
Do you have health insurance?
*
Yes
No
When would you like to move in?
*
-
Month
-
Day
Year
Date
Are you willing to follow house rules? (no drugs or alcohol, quiet hours, curfew, cleanliness, no guests)
*
Yes
No
How did you hear about us?
*
Is there anything else you would like like us to know?
Submit
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