Safehouse and Sparrow's Nest Program Application

Level III Residential Program Application

Please fill out the online application for acceptance into the Safehouse or Sparrow's Nest. Complete all questions as accurately as possible. If the form won't submit, make sure you have filled out all required fields (designated by a red asterisk (*). If the answer does not apply to you, enter N/A. A member of our staff will get back to you within three business days. If you do not hear from us, please call the Safehouse at 304-763-7655 or Sparrow's Nest at 681-207-7258.
Program Selection and Applicant Identity
Recovery Center Applying To
Sex at Birth
Gender
Applicant Name

First NameMiddle NameLast Name
Previous Name / Other Names Used
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Where/with whom have you been living?
Homeless?
Race / Ethnicity
Date of Birth

MonthDayYear
Social Security Number
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Referral and Emergency Contact
Date of Referral

MonthDayYear
Referred By (Name)
If this form is being filled out by someone other than the applicant, list your name and relationship.
Phone Number of Referrer or Other Person Filling Out the Form
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Relationship
Emergency Contact Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Family and Child Welfare
Marital status
Have you been a victim of domestic violence or are you fleeing a violent situation?
Do you have custody of your children?
Children's ages
Are social services involved regarding your children?
CPS worker name

First NameLast Name
CPS worker phone number
Please enter a valid phone number.Format: (000) 000-0000.
CPS county/state
CPS lawyer name

First NameLast Name
CPS lawyer phone number
Please enter a valid phone number.Format: (000) 000-0000.
Substance Use and Supervision
Drug(s) of Choice and Other Addictions
Give a brief description of your journey with substance abuse, i.e., how old you were when you started, how many times you've been to rehab, the longest you've been sober, etc.
Are You Experiencing Withdrawal Symptoms?
Level of Current Supervision

Other
Other Supervision Type
Name of your Parole/Probation/Home Confinement Supervising Officer:

First NameMiddle NameLast Name
Supervising Officer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Supervising Officer’s County/State
Attorney’s Name

First NameMiddle NameLast Name
Attorney’s Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current or Pending Charges/Conviction?
Explain Current or Pending Charges/Conviction and Charges and Conditions of Probation/Parole. Write N/A if it doesn't apply.
Health and Medical History
Able to walk 3 miles per day and stand at least 30 hours per week?
Do you have any health conditions?
Will these health conditions prevent or limit your participation in our work program? Residents need to be able to climb stairs, lift heavy objects, and work or attend classes at least 30 hours a week.
List and describe any health issues you have had or are having, including surgeries. How do they affect your life now?
Medical conditions
Are there any additional conditions not listed? If yes, please list. If no, enter N/A.
Current medications and medications used or prescribed in the past year. Enter N/A if none.
Have you tested positive for HIV, hepatitis, or another communicable disease? Testing positive does not disqualify you from the program.
Explain your communicable disease condition(s). Enter N/A if you do not have and have never had a communicable disease.
Have you ever been diagnosed with a mental health condition?
Describe past and present symptoms for each diagnosis. Write N/A if it doesn't apply.
Have you ever received mental health treatment?
List and describe mental health treatment (where, when, duration, and prescriptions), Write N/A if it doesn't apply.
Have you ever had thoughts or plans, or taken action, to hurt yourself or someone else?
Explain your self-harm or harm-to-others response. Write N/A if it doesn't apply.
Additional health and medical information that we should know about
Income, Veteran Status, and Certification
Do you currently have a source of income?
Describe your income source(s).
Are you a veteran?
Veteran details
Acknowledgment and certification
Please Read and Check Each Agreement:
By typing my name below, I am electronically signing this form and attesting that these answers are complete and true.

First NameLast Name
Applicant signature dates

MonthDayYear
Hour MinutesAM/PM Option
Should be Empty:

Level III Residential Program Application

Program Selection and Applicant Identity

Referral and Emergency Contact

Family and Child Welfare

Substance Use and Supervision

Health and Medical History

Income, Veteran Status, and Certification