APPLICATION FOR RESIDENCY
  • APPLICATION FOR RESIDENCY

    Sisters Beauty & Wellness Transitional Center
  • Please note: Incomplete applications will not be processed. Please make sure to answer all questions as thoroughly as possible to the best of your ability.

  • Basic Information

  • Date of Birth
     - -
  • Today's Date:
     - -
  • Format: (000) 000-0000.
  • Is it OK to call?
  • Is it OK to leave message?
  • Marital Status
  • Have You Resided in Similar Housing Before?
  • EMERGENCY CONTACT INFO

  • Format: (000) 000-0000.
  • Is there anyone you wish we NOT contact or leave a message with?
  • Client Intake Form

  • Date of Birth:
     - -
  • Format: (000) 000-0000.
  • Background Information

  • Are you currently employed?
  • Have you been in any other housing programs?
  • Health and Wellness

  • Do you have any physical or mental health diagnoses?
  • Do you currently take any medications?
  • Do you have a primary care provider?
  • Format: (000) 000-0000.
  • Emergency Contact

  • Format: (000) 000-0000.
  • EMPLOYMENT (From most recent to past):

  • Rows
  • EDUCATION (From most recent to past):

  • Rows
  • Have you defaulted on any student loans?
  • Have you Ever Been diagnosed or supected to have a Learning Disability?
  • TRANSPORTATION

  • Do you have a valid driver's license
  • Do you own a car?
  • Is it registered in your name?
  • Do you have auto insurance?
  • CRIMINAL HISTORY INFORMATION

  • Have you ever been arrested/ convicted of a crime?
  • Where the charges dropped?
  • Have you ever been convicted of a felony?
  • Do you have a parole or probation officer?
  • Is there currently a restraining order on/against you?
  • Do you currently have a restraining order in place on/against someone?
  • Are you or have you ever experienced domestic violence or sexual assault against you?
  • MEDICAL HISTORY-SELF

  • Do you have medical insurance?
  • Format: (000) 000-0000.
  • Date of Last Physical:
     - -
  • Format: (000) 000-0000.
  • Date of Last Visit
     - -
  • Rows
  • MENTAL HEALTH

  • Are you or have you ever been involved in any counseling or therapy?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Are you or have you ever been diagnosed with a mental illness?
  • Have you ever been hospitalized for mental health?
  • Rows
  • SUBSTANCE/ALCOHOL HISTORY

  • Are you or have you ever used any narcotic or illegal drug including marijuana?
  • Have you ever been treated for substance or alcohol abuse?
  • Successfully graduate?
  • Are you in recovery?
  • Do you currently have a sponsor?
  • Are you currently drinking alcohol?
  • If yes, how often do you drink in a week?
  • Should be Empty: