Bridge House Housing Application

Application for Housing at The Bridge House

All information is held in strictest confidence. At no given point is information disclosed or shared without client’s written consent.

Please note that all information marked with an * must be completed or you will not be able to submit the application online.

Full Name*

First NameMiddle NameLast Name

Date*

Date

Social Security Number*

Numbers only - no dash

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date*

MonthDayYear

Cell Phone Number*

Fill in with 000-000-0000 if not applicable.

Work Phone Number*

Fill in with 000-000-0000 if not applicable.

Home Phone Number*

Fill in with 000-000-0000 if not applicable.

E-mail*

Fill in with none@none.com if you don't have one.

Which Bridge House are you applying to?

What is your current living situation?*

Type your answer

What is your marital status?*

Choose one answer from the drop-down list.

AlcoholicDrug AddictNeither

Date of last drink or drug usage:*

Give at least month and year.

YesNo

In-patientOut-patientNone

If you are in treatment, where?*

Type none if not applicable.

Date Entered Treatment?

How many NA, HA, AA, CA or Celebrate Recovery meetings do you attend each week?*

YesNo

If yes, give name of recovery house, city and state.*

Type none if not applicable.

YesNo

What is your monthly income from all sources?*

YesNo

WelfarePensionChild supportOther

YesNo

If yes, who do you report to?*

Give full name of officer and phone number.

YesNo

If yes, what state is it issued in?*

.

Provide driver's license number.*

.

YesNo

If yes, what for?*

Provide names of all conditions for which you are under a doctor's care.

YesNo

List medicine name, how much you're taking and when:*

What is your doctor's name?*

Give full name.

Doctor's Phone Number*

Area CodePhone Number

What is the date of your last T.B. test?*

Give at least month and year or state 'don't know'..

YesNo

If yes, please give explanation (include length of stay, diagnosis and treatment):*

Type none if not applicable.

YesNo

If yes, please give explanation (include any professional treatment, diagnosis and symptoms):*

Type none if not applicable.

YesNo

If yes, please give explanation (include any professional treatment, diagnosis and duration):*

Type none if not applicable.

YesNoUnsure

List two emergency contacts:

Emergency Contact #1*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Relationship*

Phone Number*

Area CodePhone Number

Emergency Contact #2:*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Relationship*

Phone Number*

Area CodePhone Number

The Bridge House is an exempt organization as described in Section 501(c)(3) of the Internal Revenue Code;

#85-2131734.

bridgehouseministry@gmail.com