Still Waters Housing Application
A * Indicates required response. If a question does not apply to you, write "N/A". You will not be able to submit application without answering * questions.
* Today's Date:
Date
*Full Legal Name:
Client first name Client last name
*Preferred Name:
Client first name
*Did you read the Still Waters Housing informational sheet?
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Before completeing the application, we require that you read the informational sheet found at this link SWH Info Sheet. You will not be able to submit application without reading.
*Have you applied with Still Waters Housing before?
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When did you apply for Still Waters previously (if applicable)?
Date
*Which house are you interested in?
Client facility
*Phone Number:
Client phone
*This phone number is a...
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*Email:
Client email
*Date of Birth:
Client birthdate
*Age:
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*Gender:
Client gender
*Social Security Number:
SSN
*Do you have a valid form of ID?
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*What form(s) of ID do you have?
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*Marital Status:
Client marital status
*Ethnicity:
Client ethnicity
*Race:
Client race
*How long have you lived in Colorado?
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*Please list all of the states where you have lived, in the last seven years.
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*Where are you currently living?
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*Address or name of current residence:
Client Address
Children
*Do you have children?
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*Are you currently pregnant?
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*Are any of your children currently living with you (if applicable)?
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If yes, how many children are living with you?
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Please list you child/ren's date of birth.
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Please list all children currently living with you (if applicable):
Family Members
If you have children not living with you, please list them below.
Family Members
Where are your children living?
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*Are you in contact with the child(ren)'s father(s)?
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*Do you have an open or ongoing custody case?
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County/State of Custody Case (if applicable):
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Case Worker Name:
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Case Worker Phone Number:
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Emergency Contacts
*Name of nearest living relative:
Family Members
*Family Member's address:
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*Family Member's phone number:
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*Emergency Contact Information (please list at least one):
Contact
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Education
*Highest level of school completed:
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*What grade?
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*Did you reveive a diploma?
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*Do you have any diagnosed learning disabilities?
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*If yes, what learning disabilities have you been diagnosed with?
Client diagnosis
*Are you interested in additional schooling/training?
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What additional schooling/training are you interested in?
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*Are you currently enrolled in classes?
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*What program/degree are you working towards?
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Credits remaining:
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*Do you owe any outstanding money for previous schooling/training?
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Amount:
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Current Debt
*Are you currently working toward debt repayment?
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*Are you interested in financial counseling?
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Employment and Work History
*Are you able to work 40 hours/week?
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*Are you currently employed?
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*Please list current employment first, followed by work history (it is not required to be currently employed):
EmploymentHistory
*Have you ever been scheduled to work between the hours of 8 PM - 6 AM?
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If so, how often?
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*Can we call your current employer as a reference?
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Employer's phone number:
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Please explain any periods of unemployment:
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Other Sources of Income
*Do you receive monthly assistance from TANF?
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How much do you receive per month from TANF?
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*Do you receive monthly assistance from SSI/SSDI?
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How much do you receive per month from SSI/SSDI?
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*Do you receive unemployment income?
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How much do you receive per month from unemployment income?
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Please list any other monthly financial assistance here:
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Legal History
*Have you ever been arrested?
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*Have you ever been convicted?
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*How many charges have you received?
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Charge #1
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Charge#1 Date
Date
Charge #1 Current Status
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Charge #1 Class
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Charge #2
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Charge#2 Date
Date
Charge #2 Current Status
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Charge #2 Class
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Charge #3
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Charge#3 Date
Date
Charge #3 Current Status
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Charge #3 Class
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Charge #4
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Charge#4 Date
Date
Charge #4 Current Status
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Charge #4 Class
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*Have you ever been incarcerated?
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*Are there any current charges pending?
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*Are you currently on parole?
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*Are you currently on probation?
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*Do you have any current or outstanding fees, fines or resitution?
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Total amount owed (outstanding and current):
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What is your monthly payment amount?
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Please list all requirements for parole/probation (meetings, classes, UAs/BAs, court appearances, etc):
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Drug & Alcohol History
*Please list your substance of choice (if applicable):
Client substances of choice
Substance 1:
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How much?
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How often?
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Last Used
Date
Substance 2:
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How much?
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How often?
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Last Used
Date
Substance 3:
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How much?
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How often?
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Last Used
Date
Substance 4:
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How much?
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How often?
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Last Used
Date
Where do you typically use/drink?
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Who do you typically use/drink with?
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*Do you believe you have an addiction?
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What is your sobriety date?
Date
What do you believe has helped you stay sober in the past?
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*Do you believe you have other addictions (eating, unhealthy relationships, spending, etc.)?
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*Please specify:
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*Have you ever participated in a recovery group, meeting or program?
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Which programs and groups?
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When was the last time you participated in a recovery group, meeting or program?
Date
List any drug/alcohol treatments below:
TreatmentCenterHistory
Please list sober living history below:
SoberLivingHistory
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Sex Industry History
*Have you ever exchanged sex for money, food, drugs, housing, etc.?
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Check all that apply in your past and/or present situation:
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Other:
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How recently have you been involved in the sex industry?
Date
*Have you ever been forced or threatened into involvement in the sex industry?
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Where/when did this happen?
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Medical Health History
*Do you have any disabilities or medical conditions that keep you from working or limit the type of work you do?
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Please explain
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Name of Primary Care Doctor if applicable:
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Location:
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*Are you currently being treated, or have you been treated in the past six months, for a medical condition?
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Please explain
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In the following section, please list all medications you are currently taking. Do not list mental health meds here.
Medication
Client allergies
*Name of Primary Care Doctor:
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*Location:
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Mental Health History
*Have you had previous counseling or mental health care?
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Date of most recent counseling/mental health care:
Date
Location:
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Situaion/Diagnosis:
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Please list all current mental health related medications:
Medication
*Are there any other previous mental health care or mental health medications we should be aware of? Please explain:
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*Are you currently seeing a psychologist/psychiatrist/counselor?
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Please list current mental health providers below:
Therapist/Clinician
*Therapist/Clinician #1: May we contact them? If yes, please list their phone number
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*Have you ever been hospitalized for psychiatric reasons?
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Please list the date, location, and reason for any previous psychiatric hospitalizations.
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Family History
*How would you describe your growing up experience? (i.e.: positive, parents were absent, abusive, raised by relatives, etc.)
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*Where did you spend most of your childhood?
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*Who was your primary parent/guardian growing up?
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*Did you ever live in a group home or foster care?
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Please list the details of your group home/foster care history. Please share the dates, how old you were, and what the circumstances were.
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*Previous generations of my family have been involved with (check all that apply):
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*Did your childhood/teenage years include any of the following? (check all that apply):
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*How would you describe your current relationship with your biological or adoptive family?
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Religious Beliefs
*Have your experiences with Christians and church been generally positive or negative? Please explain your answer:
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*Have you ever been involved in a local church as an adult?
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What Church?
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Location of Church
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*Are you open to exploring Christian spirituality as part of this program?
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Do you have concerns about a Christian program? If so, what are your concerns?
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Present Difficulties
*What do you feel is the cause of your present difficulties?
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*How can we help you?
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*Name two goals that you have for yourself:
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*Have you been in any Open Door or Providence Network homes before?
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*Which home? When were you in the home?
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Experience Checklist
Please share your experiences with the following circumstances. You can check both "Currently Experiencing" and "Have Experienced in the Past" if applicable.
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Currently Experiencing (within the Previous 7 Days) |
Have Experienced in the Past |
| Abusive Relationships |
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| Anxiety |
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| Binging (Over Eating) |
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| Difficulty Concentrating |
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| Compulsive Behavior |
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| Cutting |
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| Domestic Violence |
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| Lack of Education |
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| Feeling Insecure |
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| Guilt |
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| Homelessness |
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| Impulsivity |
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Currently Experiencing (within the Previous 7 Days) |
Have Experienced in the Past |
| Lack of Goals |
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| Loneliness |
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| Loss of a Child |
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| Anorexia |
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| Nervousness |
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| Poor Body Image |
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| Paranoia |
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| Issues Parenting |
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| Passive Agressiveness |
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| Physical Disability |
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| Rapid Heart Beat |
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| Relapse |
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Currently Experiencing (within the Previous 7 Days) |
Have Experienced in the Past |
| ADD/ADHD |
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| Social Anxiety |
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| Sadness |
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| Stomach Trouble |
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| Skipping Class |
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| Sexual Abuse |
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| Uncontrolled Anger |
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| Appetite Problems |
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| Co-dependency |
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| Confusion |
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| Cult Involvement |
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| Depression |
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Currently Experiencing (within the Previous 7 Days) |
Have Experienced in the Past |
| Difficulty Making Decisions |
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| Low Energy |
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| Finance Issues |
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| Hatred |
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| Homicidal Thoughts |
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| Injuring Self |
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| Chronic Illness |
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| Loss and Grief |
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| Mania |
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| Mood Swings |
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| Nightmares |
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| Obsessive Behavior |
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Currently Experiencing (within the Previous 7 Days) |
Have Experienced in the Past |
| Paralysis |
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| Physical Abuse |
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| Poor Social Skills |
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| Prescription Abuse |
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| Racing Thoughts |
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| Rejection |
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| Hyperactivity |
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| Sleep Problems |
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| Suicide Attempt |
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| Stress |
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| Spirituality Issues |
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| Unemployment |
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Currently Experiencing (within the Previous 7 Days) |
Have Experienced in the Past |
| Abortion |
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| Bitterness |
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| Excessive Crying |
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| Divorce |
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| Death of a loved one |
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| Disorganization |
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| Eating Disorder |
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| Fear for life |
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| Gambling Addiction |
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| Headaches |
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| Hopelessness |
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| Irritability |
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Currently Experiencing (within the Previous 7 Days) |
Have Experienced in the Past |
| Legal Matters |
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| Rapid Weight Change |
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| Marriage trouble |
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| Memory Loss |
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| Numbness |
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| Chronic Pain |
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| Verbal Abuse |
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| Pornography |
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| Recklessness |
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| Resentment |
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| Rape |
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| Shame |
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Currently Experiencing (within the Previous 7 Days) |
Have Experienced in the Past |
| Same-Sex Attraction |
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| Sexual Addiction |
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| Suicidal Thoughts |
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| Poor time management |
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| Skipping work |
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If you have faced challenges not mentioned, please describe below:
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By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
I attest that I have answered all questions accurately and honestly to the best of my recollection: (please sign below)
Signature
Date
References
I (name) Text field hereby release the below named organizations and/or persons from confidentiality for the purposes of discussing my treatment with the staff of Still Waters Housing, Open Door Ministries.
Date
Please list both personal and professional references below. Suggested references: probation or parole officers, case managers, mental health providers, counselors, psychiatrists, friends, family, or employers.
Name of Reference #1
*Text field
* Phone Number or email
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*Relationship to You
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* How long have you known him or her?
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* Which county/office do they work in? (If applicable)
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Name of Reference #2
*Text field
* Phone Number or email
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*Relationship to You
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* How long have you known him or her?
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* Which county/office do they work in? (If applicable)
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Name of Reference #3
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* Phone Number or email
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* Relationship to You
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* How long have you known him or her?
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* Which county/office do they work in? (If applicable)
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I also release the staff of Still Waters Housing from confidentiality for the purposes of discussing my treatment with the above named organizations and/or persons.
Signature:
Signature
Date:
Date
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Background Check:
I authorize Open Door Ministries and/or its agents to make an independent investigation of my background, references, character, past employment, education, credit history, criminal or police records, and motor vehicle records including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my Application and/or obtaining other information which may be material to my qualificiations for my acceptance now and, if applicable, during the tenure of my stay with Open Door Ministries. I release Open Door Ministires and/or its agents and any person or entity, which provides information pursuant to this authorization, form any and all liabilities, claims or law suits in regards to the information obtained form any and all of the above referenced sources used.
Signature:
Signature
Date:
Date
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