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:
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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?
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How many? Text field Ages Text field
Highest grade completed:
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Need to work on your GED?
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Have you ever applied to be, or been, a resident of WFCI?
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If yes, when?
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Why do you want to come to WFCI?
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How did you hear about WFCI?
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Why can’t you live with a family member?
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Medical Considerations - I have experienced or been treated for:
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Please provide explanations for all boxes checked above:
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Current Prescription Medications:
Medication
Substance Abuse History
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Age of First Use |
Route of Administration |
Date of Last Use |
Currently Using? |
| Alcohol |
Text field |
Text field |
Date |
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| Methamphetamine |
Text field |
Text field |
Date |
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| Cocaine/crack |
Text field |
Text field |
Date |
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| Heroin |
Text field |
Text field |
Date |
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| Hallucinogens |
Text field |
Text field |
Date |
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| Cannabis/THC |
Text field |
Text field |
Date |
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| Fentynal |
Text field |
Text field |
Date |
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| Other |
Text field |
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Date |
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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:
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Please provide a brief explanation for boxes checked above:
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Do you have any pending court cases? Radio buttons
Describe:
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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:
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Amount: Text field |
Employer: Text field |
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Amount: Text field |
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Amount: Text field |
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Amount: Text field |
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Amount: Text field |
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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