Women's Faith Home Ministry — Residential Program Application

Women's Faith Home Ministry — Residential Program Application

Please complete this application thoroughly to help us evaluate your eligibility and provide appropriate care.
Thank you for your interest in the Women's Faith Home. Please complete this application thoroughly and honestly. All information is kept strictly confidential and is used solely for the purpose of determining program eligibility and providing appropriate care.
SECTION 1 — PERSONAL INFORMATION
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Age
Social Security Number
Sex
Marital Status
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Previous Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Driver's License or ID Number
Date of Application

MonthDayYear
Date
SECTION 2 — EMERGENCY CONTACT
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Relationship
Emergency Contact Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
SECTION 3 — FAMILY BACKGROUND
Briefly describe your father and your relationship with him
Briefly describe your mother and your relationship with her
Have you been previously married?
If yes, list all former spouses including Name, Date Married, and Current Status of Marriage
Do you have children?
If yes, list all children including Name, Sex, Age, and Who they are currently living with
SECTION 4 — EDUCATION BACKGROUND
Did you receive your high school diploma or GED?
If yes, what year?
List all high schools or secondary schools attended (Name of School, Location, Dates Attended, Grade Completed)
List any colleges or trade schools attended (Name of School, Location, Dates Attended, Degree or Certificate Earned)
SECTION 5 — MILITARY SERVICE
Have you served in the military?
If yes, list Branch of Service, Dates of Service, and Discharge Status
SECTION 6 — EMPLOYMENT BACKGROUND
List your jobs from the past five years, most recent first. Include: Employer Name, Position, Dates Employed, and Reason for Leaving
SECTION 7 — MEDICAL AND PHYSICAL HEALTH
Please answer the following health questions as completely and honestly as possible. This information helps us ensure we can provide appropriate care and support during your stay.
Do you currently have any medical conditions that require a doctor's care?
If yes, please describe your medical conditions
Do you have any upcoming medical appointments?
If yes, please describe the appointments and which type of doctor
Please list any serious illnesses you have had in the past five years
Have you been hospitalized in the past five years?
If yes, list the Hospital Name, City, Dates of Stay, and Diagnosis for each hospitalization
Name and Address of your current primary care physician
Are you currently taking any prescription or over-the-counter medications?
If yes, please list each medication, the dosage, and what it is prescribed for
Please check any medical conditions or symptoms you currently have or have had
Has anyone in your immediate or extended family been diagnosed with any of the following?
SECTION 8 — MENTAL HEALTH BACKGROUND
Mental health information is confidential and is used to ensure we connect you with the right support and resources.
Have you ever received pastoral, psychological, or psychiatric counseling or mental health treatment?
If yes, please describe the type of treatment, the provider, approximate dates, and the reason you sought help
Have you ever been involuntarily committed or institutionalized for a mental health condition?
If yes, please provide details including facility, dates, and reason
Have you or anyone in your immediate family ever threatened or attempted suicide?
If yes, please briefly describe the circumstances
Please check any mental health symptoms or diagnoses you currently experience or have been diagnosed with
SECTION 9 — SUBSTANCE USE HISTORY
This section is required and will not disqualify your application. Honesty here helps us place you in the most appropriate level of care.
Drug and Alcohol History: For each substance used, please list the Type of Substance, Age First Used, How Long Used, Method of Use, and Frequency of Use
Past Detox or Medical Withdrawal Treatment: List Name of Center, Location, and Dates Attended
Past Programs or Support Groups: List Name of Program or Group, Location, and Dates Attended
Please check any of the following symptoms or conditions you have experienced, NOT related to substance use
SECTION 10 — LEGAL BACKGROUND
Have you ever been arrested?
If yes, please describe the reason, the date, and the outcome for each arrest
Have you ever served time in jail or prison?
If yes, list the Facility Name, Location, Dates, and Reason for each incarceration
Are you currently on probation?
If yes, list your Probation Officer's Name and Phone Number
Are you currently in violation of your probation?
Are you currently on parole?
If yes, list your Parole Officer's Name and Phone Number
If on probation or parole, please describe the reason
Name and Phone Number of your public defender (if applicable)
Have you ever been charged with or convicted of a sex offense?
SECTION 11 — SEXUAL HISTORY
The following questions relate to behaviors that are not permitted during participation in the Faith Home program. Please answer honestly.
Do you currently identify as homosexual or bisexual?
Have you had homosexual experiences in the past?
SECTION 12 — SPIRITUAL BACKGROUND
What is your religious background or affiliation?
Do you consider yourself a born-again Christian?
Please explain your answer
Are you currently attending church?
If yes, what is the name and location of your church?
How often do you attend church?
Please check any of the following beliefs that apply to you
What is your father's religion? Does he practice it?
What is your mother's religion? Does she practice it?
What is your stepfather's religion (if applicable)? Does he practice it?
What is your stepmother's religion (if applicable)? Does she practice it?
Any additional comments about your spiritual background or beliefs
SECTION 13 — GENERAL INFORMATION
How were you referred to the Lighthouse Gospel Mission, Inc. and Faith Home?
Why do you want to come to the Lighthouse Gospel Mission, Inc. and Faith Home? Please be as specific as possible.
Is there anything else you would like us to know about yourself that has not been addressed in this application?
Should be Empty:

Women's Faith Home Ministry — Residential Program Application

SECTION 1 — PERSONAL INFORMATION

SECTION 2 — EMERGENCY CONTACT

SECTION 3 — FAMILY BACKGROUND

SECTION 4 — EDUCATION BACKGROUND

SECTION 5 — MILITARY SERVICE

SECTION 6 — EMPLOYMENT BACKGROUND

SECTION 7 — MEDICAL AND PHYSICAL HEALTH

SECTION 8 — MENTAL HEALTH BACKGROUND

SECTION 9 — SUBSTANCE USE HISTORY

SECTION 10 — LEGAL BACKGROUND

SECTION 11 — SEXUAL HISTORY

SECTION 12 — SPIRITUAL BACKGROUND

SECTION 13 — GENERAL INFORMATION