Whole Family Community Initiative, Inc Resident Application

POTENTIAL RESIDENT APPLICATION FOR:

House of Ruth Fresh Start Home

&

Pathway to Damascus Recovery Center for Men

 

Please answer all questions accurately and correctly. Please do not leave any blanks on this application, as this will delay processing. Whole Family Community Initiative, Inc. (WFCI) is a non-profit 501 (3) (c) umbrella for the House of Ruth and Pathway to Damascus. WFCI reserves the right to deny applicant admission to the program. 

 

INFORMATION ABOUT YOU 

My application is for: 

Radio buttons

Date Date Name Client first name Client last name Phone number: Client phone

Name you go by Client nickname

 Present Address Client Address Client City Client State Client Zip 

County Text field 

 Previous Address Text field Text field Text field Text field

 County Text field

Date of Birth Client birthdate Age Text field

Social Security Number SSN(Optional)

 Height Text field  Weight Text field  Eye Color  Text field Hair Color  Text field Race Client race

 Gender:

Client gender

Marital Status:

Client marital status

Do you have children? 

Radio buttons

How many?  Text field Ages Text field

Highest grade completed:

Text field

Text field

Need to work on your GED?

Radio buttons 

Have you ever applied to be, or been, a resident of WFCI? 

Radio buttons

If yes, when? 
Paragraph

Why do you want to come to WFCI? 

Paragraph

How did you hear about WFCI?  

Paragraph

Why can’t you live with a family member?

Paragraph

Medical Considerations - I have experienced or been treated for: 

Checkboxes

Please provide explanations for all boxes checked above: 

Paragraph

Current Prescription Medications:


Medication

 

Substance Abuse History 

  Age of First Use Route of Administration Date of Last Use Currently Using?
Alcohol Text field Text field Date Radio buttons
Methamphetamine Text field Text field Date Radio buttons
Cocaine/crack Text field Text field Date Radio buttons
Heroin Text field Text field Date Radio buttons
Hallucinogens Text field Text field Date Radio buttons
Cannabis/THC Text field Text field Date Radio buttons
Fentynal Text field Text field Date Radio buttons
Other Text field Text field Date Radio buttons

 

How long have you known your alcohol/dryg use to be problematic? Text field

Please list any past treatment/detoxificiation programs in which you were a participant: 

TreatmentCenterHistory

 

Legal History

Applicants must obtain and submit a copy of their criminal history report to WFCI from the local city police/sheriff's department. 

Have you ever been arrested/incarcerated? Radio buttons

If yes, how many times? Text field

Have you been incarcerated for any of the following: 

Checkboxes 

Please provide a brief explanation for boxes checked above: 

Paragraph

Do you have any pending court cases? Radio buttons

Describe: 

Paragraph

Name of legal representative: Text field

Judge's name: Text field Court: Text field County: Text field

Are you currently on probation or parole? Radio buttons

If yes, how long? Text field

How much time remaining? Text field How often do your report? Text field

Report by: Checkboxes

Name of probation/parole officer: Text field Address: Text field County: Text field Phone: Text field

Source of Income:

Checkboxes Amount: Text field Employer: Text field
Checkboxes Amount: Text field  
Checkboxes Amount: Text field  
Checkboxes Amount: Text field  
Checkboxes Amount: Text field  

 

Acknowledgements and Signatures

In completing this application and initialing the statements below, I hereby acknowledge: 

WFCI is a faith-based facility and, as a result, I will be required to attend church services three times per week, attend prayer meetings, and attend bible studies and chapel services. Initials Text field

I must commit to working a highly-disciplined spiritually-based program for the next 18 months, once admited to WFCI. Initials Text field

WFCI does not permit the use of alcohol, drugs, while in the program. Violation will subject me to discharge from the program. Initials Text field

WFCI has a strict dress code; enforcing modesty and good personal hygiene. I agree to be appropriately dressed and well-groomed daily. Initials Text field

I willingly submit to the rules, regulations, and policies of WFCI and allowing Christ to change my life. Initials Text field

WFCI will conduct periodic drug tests/screens, and a positive result may result in immediate discharge from the program, as well as notification to my probation/parole officer as mandated by law, if one is assigned. Initials Text field

WFCI is not responsible for my medical needs/attention, due to transportation to non-program related venues. Initials Text field

WFCI has my authorization to conduct a criminal background check. Initials Text field

WFCI staff may talk with individuals who have provided treatment to me in the past. This may include, but is not limited to, doctors, hospitals, clinics, or other mental/health care facilities. Initials Text field

I, Text field, acknowledge that, to the best of my knowledge, I have provided true and accurate information in completing this application. Furthermore, I authorize WFCI to verify validity when deemed necessary. I give WFCI staff permission to communicate with my support network to determine eligibility for admission. I also allow WFCI to speak with my representative, legal or otherwise, to assist with admission, recovery, or aftercare. I understand that any false or misleading information could result in denial for admission, or discharge from the program. 

By signing below, I acknowledge that I have received, read, or have read to me, the General Release of Liability agreement, the Housing Authority, the Specific Releases Form, the WFCI handbook, and the general rules and regulations. I have been given the opportunity to review this application and all other agreemtns hereto, with legal counsel of my choosing. I have executed the general release agreement and housing agreement voluntarily, free of duress, coercion, or undue influence. 

Signature: Signature Date: Date