• The Open Door House Resident Application

    Thank you for your interest in The Open Door House program. Please complete the resident application below. Should you have any questions along the way, we invite you to reach out to our Program Director, Symone' Thompson at s.thompson@theopendoorhouse.org

  • Applicant Information

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • US Citizen?

  • Emergency Contact

  • Format: (000) 000-0000.

  • Children & Family

  • Are you pregnant?*
  • Do you have a baby on the way?
  • Do you have any children?*
  • Sex*
  • Are your children living with you?

  • Education

  • Do you want to go to college?
  • Do you plan on going back to school?

  • Employment & Career

  • Previous Employer A - Start Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Previous Employer A - End Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Previous Employer B - Start Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Previous Employer B - End Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Previous Employer C - Start Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Previous Employer C - End Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Legal History & Behavior

  • Have you ever been arrested?*

  • Willingness

  • Would you be willing to meet with a therapist monthly?*
  • If asked, are you willing to take random drug tests for the first 30 days?*
  • If not, would you be willing to participate in drug use sessions with a therapist?

  • Foster Care

  • Former foster youth*

  • Risk/Incident History

  • Fire Setting*
  • Fire Setting Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Violent/Assault*
  • Violent/Assault Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Property Destruction*
  • Property Destruction Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gang Affiliation*
  • Gang Affiliation Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sexual Offense*
  • Sexual Offense Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Charges Pending*
  • Charges Pending Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Substance Use*
  • Substance Use Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Suicidal Thoughts*
  • Suicidal Thoughts Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Suicide Attempts*
  • Suicide Attempts Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Baker Act (i.e., involuntary commitment)*
  • Baker Act Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Diagnoses

  • Medications

  • Therapist

  • Format: (000) 000-0000.

  • Person Completing Form

  • Format: (000) 000-0000.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: