Firm Foundations Ministries

Transitional Housing Application

GENERAL INFORMATION

Full Name:   Date:

DOC, BOP, or Booking# Facility and Unit 
Address (Prison address, if applicable):
Release Date:
Phone Number: 
Email Address: 

Referred By: 

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

Social Security #
Client Gender: 

Birth Date: City/State of Birth
Race: Height:Weight:
US Citizen?

Primary Language Spoken 
Valid Drivers License?

List Restrictions:
Are you a Veteran? Branch of Service:
Type of Discharge:

 

EMERGENCY CONTACTS

 

SECTION 1: FAMILY HISTORY

What is your marital status?

Do you have a significant other (boyfriend or girlfriend)?
Name of spouse or significant other:
Describe your relationship with your spouse

 
Names and ages of children:

Describe your relationship with your children: 
How will you respond when FFM tells you that you cannot have contact with a family member or friend?

Please describe your relationship with your family:
Mother
Father
Step-Mother
Step-Father
Guardian
Siblings
What type of discipline was used in your home?

 

SECTION 2: CRIMINAL BACKGROUND AND HISTORY

Have you been in juvenile detention?

What age(s)?
What is the cumulative amount of time have you served in prison?
How many times have you been in prison? What dates?
How many times have you been in jail? What dates?
List all crimes for which you have been indicted and/or convicted, and length of time served for each.

For what crime(s) are you currently serving time?

Have you ever been charged with or convicted of a sex crime?
If Yes, please explain
Have you ever been charged with or convicted of domestic violence?
If yes, please explain
Do you currently have a restraining order against you?
If yes, when does it expire? Who filed it?
What is your relationship to them?
Have you been affiliated with any gangs?
If yes, which gangs, what was your age, and for how long were you affiliated
Do you have any unresolved conflicts with people outside prison?
If yes, please explain.

Do you plan to apply for an early release opportunity?

If yes, please explain
How long will you be on parole?
How long will you be on probation?
Describe and explain your disciplinary record inside prison

 

SECTION 3: REENTRY

 
How will you respond when FFM enforces a rule which you don’t understand or with which you disagree?

What concerns do you have about your upcoming release?
What difficulties do you believe you will face upon release? List them in order with the most difficult first.

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

In No, Please explain:

Will you have transportation upon your release?

Do you own your own vehicle?

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

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

 
 

  

  

 

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: 
Name and Relationship: 
Name and Relationship: 
Name and Relationship: 

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

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

SECTION 4: EMPLOYMENT AND FINANCES

Do you currently have a job?

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

If yes, what amount are the deductions?

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

 

To Whom?


Educational
What specific training have you had in prison?
What specific training have you had outside of prison?
Apprenticeship?
What is your employment history?

Will you have a job upon your release?

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

Do you have physical or mental limitations that would prevent you from working?

If yes, please explain
Do you plan to apply for Supplemental Security Income (SSI)?
If yes, why are you applying?
Have you applied for SSI before? If yes, when?
How do you plan to pay your rent upon release?
How will you respond when you are seeking employment and find a job, but FFM decides the job is not in your best interest?


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?
If no, please explain

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

Living within your financial means? 

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

SECTION 5: SPIRITUAL LIFE

Do you consider yourself a Christian?

Describe your church background
Describe your “born again” experience
How would others know you are a Christian?

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

Do you attend regular Bible studies and/or worship services?

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:
Service/Study and Times per month:
Service/Study and Times per month:
Service/Study and Times per month:
Service/Study and Times per month:
If no, why not?

Describe your prayer life
How often do you read and study the Bible?
Do you spend time and connect with other Christians?

If no, why not?
Do you have a “life verse” or a verse that has special meaning to you?

SECTION 6: MEDICAL HISTORY

Please check any that apply to you and give an explanation where applicable.

 

  

Please specify
Please specify

Please list all medications you currently take.

 
Disabilities including finger, hand, arm, leg problems, etc., including amputation. Please specify
Back Problems. Please specify
Joint replacements. Please specify :
Please list any other medical conditions:
Please list all surgeries and the year the surgery was done:

Please list any health problems you are presently experiencing and/or any procedures you need:

Please list all known allergies

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

SECTION 7: MENTAL HEALTH AND ADDICTION HISTORY

Have you ever been diagnosed with or treated for mental illness? 

If Yes, list the type of illness and any medications prescribed:  
When did this condition begin? 

Do you ever hear "voices" or have other auditory hallucinations? 

If Yes, when did this condition begin? 

Do you ever have visual hallucinations? 

If Yes, when did this condition begin? 

Have you ever been diagnosed with Obsessive Compulsive Disorder (OCD) or have OCD tendencies? 

If Yes, explain: 

Have you ever had suicidal thoughts or attempted suicide? 

If Yes, please explain: 

List any professional counseling you have had:

Have you ever abused or been addicted to alcohol?

Beginning age
If yes, what types of alcohol?
When was the last time you drank alcohol?

Have you ever abused or been addicted to drugs?

Beginning age
If yes, what types of drugs?
When was the last time you used drugs?
Have you used drugs in prison? If yes, what types of drugs?
Have you ever struggled with other types of addiction?

If yes, what type?

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

Are you willing to participate in programs that address addictive behavior prior to and after your release? 

If no, please explain

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

If Yes, please list the facility information below:

Were you sexually abused?

Your age How long?
By whom:

Were you physically abused?

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

Any Additional Notes: