Humble House Application 2026

Humble House Application 2026

Please complete this application in full. Incomplete applications may not be considered for interview.
OFFICE USE ONLY
Interviewed By (Office Use Only)
Interview Date (Office Use Only)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Accepted? (Office Use Only)
Acceptance Date (Office Use Only)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Letter sent? (Office Use Only)
Notes for pickup/intake (Office Use Only)
Reason if not accepted (Office Use Only)
Additional Notes (Office Use Only)
APPLICANT INFORMATION
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Race
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Other Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Program Interest
Facility Information (if applicable)
Facility Contact Person
Upcoming Court Appearance Date (if applicable)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Court Appearance Location
Reason/Charges for Court Appearance
EMERGENCY CONTACT
Emergency Contact Name

First NameLast Name
Relationship to you
Emergency Contact Address
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email
example@example.com
IDENTIFICATION & LEGAL
Do you have a Social Security Card?
Social Security Number (last 4 digits only)
Do you have a Picture ID?
ID Number
State of Issue
Is your license valid?
Current housing status

Other
Current living address (if applicable)
City/State/Zip
Have you been released from a correctional facility in the last 6 months?
If yes, what facility?
How long was incarceration?
Have you ever been registered as a sex offender/predator?
Have you ever been charged with child neglect or abuse?
If yes, please explain
Are you currently on probation?
Charge/Offense
Probation Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Probation End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Any felony convictions within the last 10 years?
Nature of offense
Date of offense

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sentence
Are you initiating or undergoing any civil proceedings (divorce, child custody, lawsuits, etc)?
If yes, please explain
PHYSICAL & MENTAL HEALTH
Any current physical health problems?
If yes, please explain
Any serious illnesses, injuries, or surgeries in the past?
If yes, please state when and what
Any physical limitations for jobs?
If yes, please explain
Will you be required to have any surgeries or medical procedures performed in the future?
If yes, please state when and what
Have you been diagnosed with any mental health problems recently or in the past?
If yes, please state when and what
Will you be required to attend any medical/mental health appointments in the future?
If yes, please state when and what
CURRENT MEDICATIONS
List all medications you are currently prescribed
Medication Name
Milligrams
Times per day
FAMILY & RELATIONSHIPS
Family Status
Spouse’s name
Spouse’s phone number
Please enter a valid phone number.Format: (000) 000-0000.
Are you in contact with your spouse?
If no, list reason
Additional Family Notes
Do you have any plans to reconcile with your spouse at a later date?
Children's Information
Child 1 Name
Child 1 Age
Child 2 Name
Child 2 Age
Where are your children located?
With whom are they located?
RELATIONSHIPS
Are you currently in a relationship?
Is this relationship with a male?
Assigned sex at birth
Gender
Sexual orientation
Relationship Notes
SPIRITUAL BACKGROUND
Do you consider yourself a Christian?
If not, what religious beliefs, if any, do you profess?
Do you consider yourself saved?
If no, why not?
If yes, please explain what you believe it takes to go to heaven
Church or house of worship you prefer to attend
Church/House of Worship Location
Who, if anyone, influenced you spiritually growing up?
SUBSTANCE USE
Are you capable of passing a drug urinalysis right now?
Are you capable of passing a breathalyzer test right now?
When was the last day you used?
Last drug used
What was/is your drug of choice (including prescription narcotics/marijuana)?
Drug Name/Type
Amount used
How often
Last use
Do you drink alcohol?
If yes, please provide
Amount consumed
How often
Last use
Do you smoke tobacco?
If yes, how much per day?
Are you willing to quit?
Have you ever been to a substance abuse or rehab facility before?
Name of facility
Location (city/state)
Check in date (mm/yy) & Length of stay
Did you graduate?
Name of facility (2)
Location (city/state) (2)
Check in date (mm/yy) & Length of stay (2)
Did you graduate? (2)
INTERVIEW QUESTIONS
Have you ever been in our program before?
If yes, when?
Where did you hear about Humble House?
What situations have led you to seek our help here?
Have you ever had an abortion?
If yes, date
SAFETY/EXPLOITATION SCREENING
Has anyone ever taken, kept, or controlled your identification or other important documents, or provided you with false identification?
Has anyone ever withheld or controlled your money in exchange for things you needed, such as food, housing, clothing, or drugs?
Has anyone ever forced, pressured, threatened, or tricked you into doing something you did not want to do, including sexual acts or working for them?
Has anyone you worked for, lived with, or did activities for ever hurt you or threatened to hurt you?
Have you ever been physically prevented from leaving a place or situation, such as through locked doors, being watched, having transportation withheld, or another method?
Have you ever felt unable to leave a situation because you feared that you or someone you cared about would be harmed?
Has anyone ever prevented or discouraged you from contacting family, friends, law enforcement, medical personnel, or others who could help you?
If you answered YES to any question above, please briefly explain (if you feel comfortable doing so)
APPLICANT CERTIFICATION
My signature below certifies that the information I have provided is true and accurate to the best of my knowledge. I understand that providing false information or omitting information requested may be grounds for my application to be denied or for later dismissal from the program.
Type in Full Name and sign below
Applicant Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Staff Signature
Date (Staff Signature)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
FINANCIAL AGREEMENT
Client Name

First NameLast Name
Amount I/Family Can Contribute
Contribution Frequency
Client Signature
Date (Client Signature)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Staff Signature (Financial Agreement)
Date (Staff Signature - Financial Agreement)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Humble House Application 2026

OFFICE USE ONLY

APPLICANT INFORMATION

EMERGENCY CONTACT

IDENTIFICATION & LEGAL

PHYSICAL & MENTAL HEALTH

CURRENT MEDICATIONS

FAMILY & RELATIONSHIPS

Children's Information

RELATIONSHIPS

SPIRITUAL BACKGROUND

SUBSTANCE USE

INTERVIEW QUESTIONS

SAFETY/EXPLOITATION SCREENING

APPLICANT CERTIFICATION

FINANCIAL AGREEMENT