Doris House Application

Loving Grace is a home that aims to EMBRACE every woman with the love of Christ, to EDUCATE them with the tools they need to succeed and live an EMPOWERED life.

Doris' House at Loving Grace
Application for Residence

Loving Grace is an equal opportunity residential facility and no potential resident will be turned away due to race, sexual orientation, disability, legal issues, or any other information that is included in this application. If no beds are available and you meet the criteria for Loving Grace, you will be placed on awaiting list until a suite is open.

We are here to help you to the best of our ability. All information provided by potential residents is for that purpose and will NOT be used against you. (If you are pregnant and/or parenting and are found to be using illegal drugs, a referral to Missouri Division of Social Services will be required and will be made by Loving Grace.

Client Information:

Full Name

Birth Date

Social Security Number

Phone Number

Marital Status

Single Married Divorced Widowed

When is your baby’s due date?

OBGYN

Address

When was your most recent appointment?

Are you in a relationship with your baby’s father?

Yes No

If you wish to provide information about your baby’s father, please complete the following:

Name

Address

Phone Number

Do you feel safe with this person?

Yes No

Do you have a relationship with your parents or previous guardians?

Yes No

If yes, please complete:

Name

Relationship

Address

Phone Number

Do you feel safe with this person?

Yes No

Have you ever been in foster care?

Yes No

Briefly describe your current family situation. Include descriptions of your relationships with immediate family members.

Do you have your own birth certificate?

Yes No

Social Security card?

Yes No

Do you have a bank account?

Yes No

If you have any outstanding debts or overdrawn bank accounts, please explain.

Health Information

Do you have any health concerns we should be aware of? Please explain fully.

Any known alllergies

Are you currently or have you in the past been treated for anxiety or depression?

Yes No

If yes, please explain.

Please list all current medications, dosages, and prescribing provider

Have you ever been hospitalized for addiction or mental health reasons?

Yes No

If yes, when?

Did you receive follow up care?

Yes No

Please explain fully, making sure you include dates of treatment and hospitalization.

Psychiatrist Name

Address

Phone Number

Counselor Name

Address

Phone Number

Additional Medical Information

Primary Care Phycisian

Address

Phone Number

Dentist Name

Address

Phone Number

Eye Care Provider

Address

Phone Number

Baby’s Pediatrician

Address

Phone Number

Other Medical Providers

Name

Address

Phone Numbers

Name

Address

Phone Numbers

Medicaid/Health Insurance Namer

ID Number

Emergency Contact Information (if different from above)

Name

Relationship

Address

Phone Number

Please list anyone with whom you want NO CONTACT due to safety concerns:

Name

Relationship

Address

Phone Number

Do you have a Protection Order?

Yes No

If yes, what county?

Education Information

What is your current (or completed) level of education

Have you ever received special education services?

Yes No

If yes please explain.

What are your current and/or future educational goals? Please explain fully.

Do you have a driver’s license?

Yes No

If yes, please complete the following:

Driver's License #

Issuing State

Expiration Date

Do you currently have a vehicle you will be using/parking while living at Loving Grace?

Yes No

If yes, please complete the following:

Make

Model

Year

Insured by

Insurance Expiration Date

License Plate Number

License Plate Expiration Date

Substance Use Information

Do you use tobacco products? (cigarettes, vapes, etc.)

Yes No

Would you pass a drug screening to enter our program?

Yes No

Have you had a problem with drugs or alcohol in the past?

Yes No

How long have you been free from the use of drugs or alcohol?

Do you attend AA or NA meetings?

Yes No

Do you have a sponsor?

Yes No

Legal Information

Please check any of the following that apply:

I have current charges pending. I am on probation or parole. I have been arrested and served time in jail. I have been questioned or charged for physical violence against another I have been questioned or charged for the sale of illegal drugs. I am currently or have been associated with a gang.

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

Are you currently employed?

Yes No

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.

Please list three references that are aware of your situation and could verify your need and willingness to work with the program.

Name

Relationship

Phone Number

How long have you known them?

Name

Relationship

Phone Number

How long have you known them?

Relationship

Name

Phone Number

How long have you known them?

If you have a child, please complete the following:

I have been or am being investigated by Children’s Division I have had my other children taken by Children’s Division I am involved in a legal custody battle

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

SIGNATURE & STAFF AGREEMENT

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

Loving Grace is a home that aims to EMBRACE every woman with the love of Christ, to EDUCATE them with the tools they need to succeed and live an EMPOWERED life.

Doris' House at Loving Grace
Application for Residence

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Quick Exit

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Single Application
(Oglesby House Application)

Pregnant or With Child Application
(Doris House Application)

Loving Grace is a home that aims to EMBRACE every woman with the love of Christ, to EDUCATE them with the tools they need to succeed and live an EMPOWERED life.

Doris' House at Loving GraceApplication for Residence

ClickHere ToQuick Exit

A new tab will open and this page will redirect to Google

Single Application(Oglesby House Application)

Pregnant or With Child Application(Doris House Application)

Doris' House at Loving Grace
Application for Residence

Click
Here To
Quick Exit

Single Application
(Oglesby House Application)

Pregnant or With Child Application
(Doris House Application)