Rhema Refuge Crisis House Qualifying Application

Rhema Refuge Crisis House Qualifying Application

Apply for transitional or emergency housing. This form helps us determine your eligibility for our programs. This form does not guaranteed housing or approval.
PLEASE READ THIS DISCLAIMER BEFORE APPLYING

Rhema's Refuge Crisis House Disclaimer
Transitional Housing Payment Disclaimer

This property is a pay-based transitional housing program. By applying, you acknowledge and agree to the following terms and conditions:

Rent is $150 per week or $300 bi-weekly, or monthly payments can be arranged depending on your selected payment schedule. Children's Rate: $75 per child (weekly) if applicable

Children Deposit $75 (first child, then $50 each additional child, up to two children total) if applicable

Rent must be paid on time and in full according to the agreed-upon schedule.
Applicants must demonstrate sufficient and verifiable income to meet these financial obligations consistently.

If you do not currently have adequate income or financial stability to support these terms, please do not complete this application at this time.

If you are in need of alternative housing options or financial assistance, we encourage you to contact our office for additional resources and referrals.

Additional Terms:

Submission of an application does not guarantee acceptance into the program.
All applicants may be subject to screening, background checks, and verification of income.
Failure to meet payment obligations may result in termination from the program.
House rules, participation requirements, and program guidelines must be followed at all times as a condition of residency.
Fees, policies, and program requirements are subject to change with proper notice.
By proceeding with this application, you confirm that you have read, understood, and agree to abide by these terms.

For questions or further assistance, please contact our office directly.
Are you completing this application on behalf of someone?
If yes, please specify your information:
Full Name, Phone Number and Relationship

APPLICANT'S INFORMATION
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Last Known Residential Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Where are you staying now:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you feel safe at your current location:

BACKGROUND CHECK AUTHORIZATION
Social Security Number
Driver's License Number:
State Issued:
Expiration Date:
Background Check Authorization Request

I hereby give permission for the Rhema Word Foundation on behalf of the Rhema's Refuge to conduct a background check as part of the application process. I understand that this may include verification of my criminal history, rental history, employment, and other relevant records.

I acknowledge that this information will be used solely to determine my eligibility for housing and will be kept confidential in accordance with applicable laws and policies.

By selecting YES below, I confirm that I have read and understand this authorization and voluntarily consent to the background check.
Do you give permission for the Rhema Word Foundation to conduct a background check?

APPLICANT'S CONTACT INFORMATION
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com

APPLICANT'S HISTORY
Are you a survivor of domestic violence?
Do you have an Emergency Protective Order (EPO) or Domestic Violence Order (DVO) on file, or are you willing to file one?
Substance Use Disclosure

To help us better understand your needs and determine appropriate placement, please answer the following:

Providing this information may assist us in connecting you with appropriate support and resources.
Do you have a history of drug and/or alcohol use?
If yes, are you currently actively using?
If applicable, please list your substance(s) of choice:Providing this information may assist us in connecting you with appropriate support and resources.
Please number each one

EMERGENCY CONTACT
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please specify:

Other
CASE WORKER/ MANAGER
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com

REFERRAL INFORMATION
WHO REFERRED YOU TO US?
COMPANY NAME
First Name Last Name Email Area Code Phone Number

CONFIDENTIALITY AGREEMENT

Rhema's Refuge Crisis House
PLEASE READ BEFORE SIGNING

Applicant Confidentiality Agreement

At Rhema’s Refuge Crisis House, the safety and privacy of every woman and child we serve is our highest priority. Due to the sensitive nature of our services, all applicants are required to agree to the following confidentiality terms as a condition of consideration for residency.

By signing this agreement, you acknowledge and agree to the following:

Confidential Location

You understand that the physical location of Rhema’s Refuge Crisis House is confidential. You agree not to share, disclose, or reveal the address, directions, or identifying details of the property to anyone not authorized by staff.
Protection of Resident Identities
You agree to respect the privacy of all residents and their children. You will not share names, personal histories, situations, or any identifying information about other individuals staying at the house.

Communication Restrictions

You agree to use caution when communicating with individuals outside the residence. This includes not posting photos, videos, or location-based information on social media or other platforms that could compromise the safety or confidentiality of the house or its residents.

Visitor and Contact Policy

You understand that visitors are not permitted unless explicitly approved by staff. You agree not to invite or allow unauthorized individuals to the property or disclose information that could lead someone to the location.

Confidential Information Handling

Any information shared with you by Rhema’s Refuge staff regarding operations, residents, or safety procedures must remain strictly confidential.
Safety Compliance
You agree to follow all safety guidelines and confidentiality policies established by Rhema’s Refuge Crisis House. These policies are in place to protect all residents and staff.

Consequences of Violation

You understand that any breach of this confidentiality agreement may result in immediate removal from the program and could impact your eligibility for future services.

By signing below, you confirm that you have read, understood, and agree to abide by the terms of this Confidentiality Agreement. You acknowledge that these measures are necessary to ensure the safety and well-being of all individuals within Rhema’s Refuge Crisis House.
Date

MonthDayYear
Date
Signature
Should be Empty:

Rhema Refuge Crisis House Qualifying Application

PLEASE READ THIS DISCLAIMER BEFORE APPLYING

APPLICANT'S INFORMATION

BACKGROUND CHECK AUTHORIZATION

APPLICANT'S CONTACT INFORMATION

APPLICANT'S HISTORY

INCOME INFORMATIOM

EMERGENCY CONTACT

CASE WORKER/ MANAGER

REFERRAL INFORMATION

CONFIDENTIALITY AGREEMENT