The Open Door House Resident Application

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
Name

First NameLast Name
Last 4 digits of SS #
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email
example@example.com
Age
Date of Birth

MonthDayYear
Date
Gender
Ethnicity
US Citizen?

Other
Primary Language
Emergency Contact
Emergency Contact

First NameLast Name
Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Children & Family
Are you pregnant?
Do you have a baby on the way?
Do you have any children?
Sex

Other
How many children?
Are your children living with you?
Education
School or Program Name
Grade
Do you want to go to college?
If so, where? (College)
What would you like to study?
Last grade completed
Last school name
If you did not complete high school and/or college, why did you stop attending?
Do you plan on going back to school?
If so, where? (Return to school)
What is your plan for returning to school?
Step-1
Step-2
Step-3
Employment & Career
Current employer
How long have you worked there?
Previous Employer A - Employer Name
Previous Employer A - Start Date

MonthDayYear
Date
Previous Employer A - End Date

MonthDayYear
Date
Previous Employer B - Employer Name
Previous Employer B - Start Date

MonthDayYear
Date
Previous Employer B - End Date

MonthDayYear
Date
Previous Employer C - Employer Name
Previous Employer C - Start Date

MonthDayYear
Date
Previous Employer C - End Date

MonthDayYear
Date
If you are not working, where have you been looking for a job?
What do you want to do as a career?
Legal History & Behavior
Have you ever been arrested?
What have you learned from that experience?
How would you handle a conflict with a roommate?
Why do you want to be in supportive housing?
What do you believe we can help you accomplish in supportive housing?
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?
Current living situation
Foster Care
Former foster youth
How long were you in foster care?
Risk/Incident History
Fire Setting
Fire Setting Date

MonthDayYear
Date
Fire Setting Notes
Violent/Assault
Violent/Assault Date

MonthDayYear
Date
Violent/Assault Notes
Property Destruction
Property Destruction Date

MonthDayYear
Date
Property Destruction Notes
Gang Affiliation
Gang Affiliation Date

MonthDayYear
Date
Gang Affiliation Notes
Sexual Offense
Sexual Offense Date

MonthDayYear
Date
Sexual Offense Notes
Charges Pending
Charges Pending Date

MonthDayYear
Date
Charges Pending Notes
Substance Use
Substance Use Date

MonthDayYear
Date
Substance Use Notes
Suicidal Thoughts
Suicidal Thoughts Date

MonthDayYear
Date
Suicidal Thoughts Notes
Suicide Attempts
Suicide Attempts Date

MonthDayYear
Date
Explanation of Most Recent Inpatient Hospitalization
Baker Act (i.e., involuntary commitment)
Baker Act Date

MonthDayYear
Date
Baker Act Notes
Diagnoses
Mental Health
Medical Conditions
Medications
Current Medication A - Name
Current Medication A - Dosage
Current Medication A - Reason
Current Medication B - Name
Current Medication B - Dosage
Current Medication B - Reason
Current Medication C - Name
Current Medication C - Dosage
Current Medication C - Reason
Therapist
Current Therapist

First NameMiddle NameLast Name
Current Therapist Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Agency Name
Person Completing Form
Name

First NameLast Name
Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Signature
Date

MonthDayYear
Date
Should be Empty: