Client Information:
Full Name
Current Address
Birth Date
Social Security Number
Phone Number
Email
Please describe your current living situation.
If yes, please complete:
Name
Relationship
Address
Phone Number
Briefly describe your current family situation. Include descriptions of your relationships with immediate family members.
What is your current (or completed) level of education?
If yes, please explain
What are your current and/or future educational goals? Please explain fully.
Medical Insurance/Medicaid Card #
If you have any outstanding debts or overdrawn bank accounts, please explain.
Health Information
Primary care physician name & number
Dentist name & number
Eye care provider name & number
Gynocologist name & number
Psychiatrist name & number
Counselor name & number
Other medical providers & number
Please list all known allergies:
Please list all current medications, dosages, and prescribing provider:
Do you have any health concerns we should be aware of? Please explain fully:
If yes, please explain.
If yes, when?
Please explain fully, making sure you include dates of treatment and hospitalization.
Psychiatrist Name
Address
Phone Number
Emergency Contact Information (if different from above)
Name
Relationship
Address
Phone Number
Name
Relationship
Address
Phone Number
Please list anyone with whom you want NO CONTACT due to safety concerns:
Name
Relationship
Address
Phone Number
If yes, what county?
Substance Use Information
How long have you been free from the use of drugs or alcohol?
Legal Information
Please explain any of the above statements that apply to you.
Provide any pending court dates and the names and phone numbers of any attorneys, probation officers, or parole officers that are, or have been involved in your case.
Employment Information
If yes, provide the below info
Where
Phone Number
Position
Salary
Please list your employment history, starting with your most recent position.
Former Employer
Position
Phone Number
Dates Employed
Reason for Leaving
Former Employer
Position
Phone Number
Dates Employed
Reason for Leaving
Do you currently receive any other type of income or support? Please explain.
1.
Name
Relationship
Phone Number
Email
How long have you known them?
2.
Name
Relationship
Phone Number
Email
How long have you known them?
3.
Relationship
Name
Phone Number
Email
How long have you known them?
Children
Please describe your child(ren)’s current living situation. (Where are they living? And who has custody?)
Optional Questions/Physical Identifiers
Race
Height
Weight
Eye Color
Hair Color
Scars
Tattoos
Piercings
I understand an application is not a guarantee of admission. Loving Grace
determines an applicant's eligibility for admission and does not disclose their
rationale for denial or admission. By signing below, I acknowledge and
understand this application will be used to consider my eligibility to live at
Loving Grace . If accepted, I will sign a expectations agreement, cupancy/rental agreement, and other documents outlining the terms for living at Loving Grace to uphold my safety and the safety of the other residents and staff. I understand my references will be contacted to verify the honesty of my statements. I also understand my eligibility will be based on the availability of space in the home and the ability of the program to assist me with my particular needs. Loving Grace
will make a decision based on this application, my interview, and available space. If my statements are found to be misrepresented at any point or I have demonstrated an unwillingness to work within the expectations and terms of my admission, I may be exited from Loving Grace immediately. I also give permission for Loving Grace to request official documents, make professional inquiries, or complete background checks on me to verify the information I have given them
Signature
Printed Name
Date
Signature of Witness
Printed Name
Date
Send Application
