GRACE HAVEN RESIDENT APPLICATION2024

Grace Haven Resident Application

Grace Haven is a non-profit organization located in Fairfield County, OH that offers a Christ centered,structured, sober living environment for women, who are in recovery from drugs and alcohol addiction. Please answer all questions, giving as much detail as possible. Applicants must be able to independently care for their personal, medical and physical needs. Acceptance into Grace Haven is at the discretion of the Ministry. Dismissal will occur if the rules and guidelines are not upheld.
Name*

First NameLast Name
DATE*

MonthDayYear
Date
Reason for application*
Referral Source: Name
Phone number
Have you been a resident before?*

yesno
Reason for leaving*
Email
example@example.com
Phone Number

Area CodePhone Number
for messages
Current Address*
Do you have an Ohio Driver License*

yesno
Driver License Number
Will you have a car for transportation while at Grace Haven?
Do you have a bank/savings account?
Do You have a current job?*

yesno
Place of Employment
Do you have children?*
Name(s)
Age(s)*

Do you have custody?
Age(s)
Will uou require supervised visitations?*

yesno
Guardian Name
Phone
Grace Haven does not permit or encourage dating at any point during residency
Date to begin at Grace Haven*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Age*
Number
Do you have any medical conditions?*

YESNO
If Yes, Please list*
Are you under mental health care/ counseling? Explain*
What medications are you currently taking?*
Physician
Doctor's Office
Phone
Do you have any Physical Limitation? We have a 3 floor house and a big hill on driveway*

YesNo
Do you have trouble walking or Climbing stairs?*

YesNo
If Yes, Please explain
Do you have any of the following?
Bi-Polar*

YESNO
Sleeping Disorders*

YESNO
Physical Abuse*

YESNOOther
Rape/ Sexual Abuse*

YESNO
Phobias*

YESNO
Heart Conditions*

YESNO
Schizophrenia*

YESNO
Diabetes*

YESNO
Nightmares*

yesno
Depression*

YESNO
Are you Pregnant*

YESNo
Have you ever tested positive for HIV?*
Hepatitis A/B/C?*
Medical*

wear glassessdental problems
Allergies*
Pregnant:*

YesNo
Due Date

MonthDayYear
Date
Current Incarceration date

MonthDayYear
Date
Date of Release

MonthDayYear
Date
Offense*
Offense: History of charges & years. Are you or have you ever been charged/convicted of violent offences?*
Phone
Case Worker or Probation Offcer
Restraining Order(s)
Names of person(s) who cannot see you
Last day of illegal Drug Use*
Age of first use?*
Longest period of abstinence from drug use*

Do you have a family history of Chemical Dependency?YesNo
Longest period of abstinence from drug use
Do you know your trigger points for using? If so, please list*
Do you have a treatment plan?*
If No, are you willing to create a treatment plan?*
Have u been in other Sober Living Homes?*

yesno
Why Did you leave?*
Residents are required to participate in all household activities

RELIGION/ SPIRITUAL WALK WITH CHRIST
Have you been Baptized?
Date

MonthDayYear
Date
Church
Describe your Christian Experience
References
Name*
Phone*
Relationship
Name
Phone
Relationship
Two contacts who would be eligible as pre-approved(non-user) for you to communicate with while at Grace Haven:
Name*
Phone*
Name
Phone
First Name* Last Name* certify that the above information is true and accurate, and I understand that deliberately falsifying any information given will lead to dismissal from Grace Haven and result in non-acceptance of my application
Signed*

Clear
Date

MonthDayYear
Date
VIA MAIL

Grace Haven Ministries PO BOX 2345 Lancaster, OH 43130
VIA EMAIL

gracehavenministries0@gmail.com
VIA WEBSITE

https://www.gracehavenministries.net/rules
Grave Haven recognizes the role of Buprenorphine and Methadone, in treatment of oplate addiction, but believes the role is best fulfilled by residential treatment facilities and in supporting living environments where staff are qualified to dispense, store and manage the use of these medications assisted treatment drugs. Residents will no longer be permitted to take the above related medications while residing at Grace Haven, Because Grave Haven is a sober living home for women, who are recovering from drugs and alcohol addiction, applications will only be accepted from women seeking a sober living environment during their transition back into society.'
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Grace Haven Resident Application

References

VIA MAIL

VIA EMAIL

VIA WEBSITE