Firm Foundations Ministries

Transitional Housing Application

GENERAL INFORMATION

Full Name:Client first name Client middle name Client last name Date:Date
DOC, BOP, or Booking#Text field Facility and Unit Text field
Address (Prison address, if applicable):Text field
Release Date:Date
Phone Number: Client phone
Email Address: Client email

Referred By: Text field

Desired Housing Location (City of Parole, if applicable):

Checkboxes

Social Security #SSN
Client Gender: Client gender
Birth Date:Client birthdate City/State of BirthText field
Race:Client race Height:Text fieldWeight:Text field
US Citizen? Checkboxes

Primary Language Spoken Text field
Valid Drivers License? Checkboxes List Restrictions:Text field
Are you a Veteran? Checkboxes Branch of Service:Text field
Type of Discharge:Text field

 

EMERGENCY CONTACTS

Contact

 

SECTION 1: FAMILY HISTORY

What is your marital status?

Checkboxes
Do you have a significant other (boyfriend or girlfriend)? Checkboxes
Name of spouse or significant other: Text field
Describe your relationship with your spouse
Paragraph
 
Names and ages of children:
Paragraph
Describe your relationship with your children: Paragraph
How will you respond when FFM tells you that you cannot have contact with a family member or friend?
Paragraph

Please describe your relationship with your family:
MotherParagraph
Father Paragraph
Step-Mother Paragraph
Step-Father Paragraph
GuardianParagraph
SiblingsParagraph
What type of discipline was used in your home?
Paragraph

 

SECTION 2: CRIMINAL BACKGROUND AND HISTORY

Have you been in juvenile detention? CheckboxesWhat age(s)? Text field
What is the cumulative amount of time have you served in prison? Text field
How many times have you been in prison? Text field What dates? Text field
How many times have you been in jail? Text field What dates? Text field
List all crimes for which you have been indicted and/or convicted, and length of time served for each.
Paragraph
For what crime(s) are you currently serving time?
Paragraph
Have you ever been charged with or convicted of a sex crime?Checkboxes
If Yes, please explainParagraph
Have you ever been charged with or convicted of domestic violence? Checkboxes
If yes, please explainParagraph
Do you currently have a restraining order against you? Checkboxes
If yes, when does it expire? Date Who filed it? Text field
What is your relationship to them? Text field
Have you been affiliated with any gangs? Checkboxes
If yes, which gangs, what was your age, and for how long were you affiliated Paragraph
Do you have any unresolved conflicts with people outside prison? Checkboxes
If yes, please explain.Paragraph

Do you plan to apply for an early release opportunity?Checkboxes
If yes, please explain Paragraph
How long will you be on parole? Text field
How long will you be on probation?Text field
Describe and explain your disciplinary record inside prisonParagraph

 

SECTION 3: REENTRY

 
How will you respond when FFM enforces a rule which you don’t understand or with which you disagree?
Paragraph
What concerns do you have about your upcoming release?Paragraph
What difficulties do you believe you will face upon release? List them in order with the most difficult first.
Paragraph

Are you willing to havea  Firm Foundations mentor for accountability in your life after you are release? Checkboxes

In No, Please explain: Paragraph

Will you have transportation upon your release? Checkboxes

Do you own your own vehicle? Checkboxes

If you are accepted into the Firm Foundation Program, are you willing to abide by the transitional plan and complete all required program materials? Checkboxes

What are your plans upon release and for the future? Please be specific.

Checkboxes Text field
Checkboxes Text field 

Checkboxes Text field  

Checkboxes Text field  

Checkboxes Text field

Please list the name and relationship of up to 4 individuals who you will utilize for a positive support system upon release (i.e., family member, friend, pastor, mentor, etc.)

Name and Relationship: Text field
Name and Relationship: Text field
Name and Relationship: Text field
Name and Relationship: Text field

What sports, interests and/or hobbies do you enjoy? Paragraph

What else should we know about your release that would help us assist you? Paragraph

SECTION 4: EMPLOYMENT AND FINANCES

Do you currently have a job? Checkboxes
If yes, what are the duties of your current job?Paragraph
How many hours do you work per week?Paragraph
What is your salary or hourly pay rate?Text field
What is the amount of your retention funds? Text field
What is the amount of your spendable funds? Text field
Do you have any deductions sent out?Checkboxes
If yes, what are the deductions?
Text field
If yes, what amount are the deductions?
Text field

Please list and give the amount of all outstanding fines, fees, and payments.
Checkboxes Text field

Checkboxes Text field

Checkboxes To Whom?Text field
CheckboxesText field

Educational EducationHistory
What specific training have you had in prison?Paragraph
What specific training have you had outside of prison?Paragraph
Apprenticeship?Text field
What is your employment history?EmploymentHistory

Will you have a job upon your release? Checkboxes
If yes, what type of job? Text field
What is the name of the company and/or employer? Text field
Where is this employer located? Text field
What wage do you expect to earn? Text field
What other financial support will you have upon release? Paragraph

Do you have physical or mental limitations that would prevent you from working? Checkboxes
If yes, please explain Paragraph
Do you plan to apply for Supplemental Security Income (SSI)? Checkboxes
If yes, why are you applying? Text field
Have you applied for SSI before? Checkboxes If yes, when? Text field
How do you plan to pay your rent upon release? Paragraph
How will you respond when you are seeking employment and find a job, but FFM decides the job is not in your best interest? Paragraph


If you are accepted into the Firm Foundations Program, are you willing to begin saving half of your earnings to apply toward your first month’s rent at the Firm Foundations House? Checkboxes
If no, please explain Text field

If you are accepted into the Firm Foundations Program, will you be committed to:

Living within your financial means? Checkboxes
Adhering to the budget developed by Firm Foundations Ministries upon your release Checkboxes
Ensuring that you pay your rent promptly? Checkboxes
payment of your rent your highest priority? Checkboxes

SECTION 5: SPIRITUAL LIFE

Do you consider yourself a Christian? Checkboxes
Describe your church background Paragraph
Describe your “born again” experience Paragraph
How would others know you are a Christian? Paragraph

Who is Jesus to you? Paragraph
What are some of the struggles you have in living a Christian life? Paragraph

Do you attend regular Bible studies and/or worship services? Checkboxes
If yes, which services and Bible studies do you attend and how often do you attend per month?
Worship Services Frequency Bible Studies Frequency
Service/Study and Times per month: Text field
Service/Study and Times per month: Text field
Service/Study and Times per month: Text field
Service/Study and Times per month: Text field
Service/Study and Times per month: Text field
If no, why not?
Paragraph

Describe your prayer life Paragraph
How often do you read and study the Bible? Text field
Do you spend time and connect with other Christians? Checkboxes
If no, why not? Text field
Do you have a “life verse” or a verse that has special meaning to you? Paragraph

SECTION 6: MEDICAL HISTORY

Please check any that apply to you and give an explanation where applicable.
Checkboxes
Checkboxes Checkboxes
Checkboxes
Checkboxes Checkboxes Text field
Checkboxes
Checkboxes Please specify Text field
CheckboxesPlease specify Text field

Please list all medications you currently take.
Medication
 
Disabilities including finger, hand, arm, leg problems, etc., including amputation. Please specifyParagraph
Back Problems. Please specify Paragraph
Joint replacements. Please specify :Paragraph
Please list any other medical conditions:Paragraph
Please list all surgeries and the year the surgery was done:
Paragraph
Please list any health problems you are presently experiencing and/or any procedures you need:
Paragraph
Please list all known allergies Client allergies

What are your plans to meet your medical needs upon your release?Paragraph
When was your last physical examination? Paragraph
 

SECTION 7: MENTAL HEALTH AND ADDICTION HISTORY

Have you ever been diagnosed with or treated for mental illness? Checkboxes
If Yes, list the type of illness and any medications prescribed: Client diagnosis 
When did this condition begin? Text field

Do you ever hear "voices" or have other auditory hallucinations? Checkboxes
If Yes, when did this condition begin? Text field

Do you ever have visual hallucinations? Checkboxes
If Yes, when did this condition begin? Text field

Have you ever been diagnosed with Obsessive Compulsive Disorder (OCD) or have OCD tendencies? Checkboxes
If Yes, explain: Paragraph

Have you ever had suicidal thoughts or attempted suicide? Checkboxes
If Yes, please explain: Paragraph

List any professional counseling you have had:
Counseling History

Have you ever abused or been addicted to alcohol? Checkboxes
Beginning age Text field
If yes, what types of alcohol? Text field
When was the last time you drank alcohol? Text field

Have you ever abused or been addicted to drugs? Checkboxes Beginning age Text field
If yes, what types of drugs? Text field
When was the last time you used drugs? Text field
Have you used drugs in prison?Checkboxes If yes, what types of drugs? Text field
Have you ever struggled with other types of addiction? Checkboxes

If yes, what type?
Checkboxes

Checkboxes Text field

What triggers cause you to resort back to addictive behaviors? (for example: association with certain individuals/places, stress, unresolved anger, fear, etc.) Paragraph
List all the programs you have competed to address your addictions.

Checkboxes Checkboxes Text field

Are you willing to participate in programs that address addictive behavior prior to and after your release? Checkboxes
If no, please explain Paragraph

Have you ever been to Inpatient or Outpatient Drug & Alcohol Treatment? Checkboxes

If Yes, please list the facility information below:
TreatmentCenterHistory

Were you sexually abused?Checkboxes Your age Text field How long? Text field
By whom:Text field

Were you physically abused? Checkboxes Your age Text field How long? Text field
By whom:Text field
 
Have you experienced suicide, murder, or other significant losses in your family? Checkboxes
If Yes who?:Paragraph
List any professional counseling you have had_Paragraph

Any Additional Notes:
Paragraph