SheBrews Application

Today's Date: Text field

Estimated Move-In Date: Text field

First Name: Client first name

Middle Name: Client middle name

Last Name: Client last name


Phone Number: Client phone 

Email: Client email

Is this your legal name?
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If not, what is your legal name? Text field

 

Former Name(s): 

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Birthdate: Client birthdate

Age: Text field

Sex: 
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Marital Status: 
Client marital status

Explain Your Current Situation:

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Are you a registered sex offender? 
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Facility Name: 
Client Referred By

County of Residence: 
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How would you describe yourself? 
Client race

Client ethnicity

Are you a member of a tribe?

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If so, which tribe? 

Text field

 

Personal History

Briefly tell us about yourself:

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What would you consider to be your weaknesses? 

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What would you consider to be your strengths? 

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Why do you want to join the She Brews Transition Program? 

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Sobriety Date 
RecoveryHistory

Number of children: Text field 

What are their situations? 
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Family Members

Do you have a personal relationship with Jesus? What does this look like for you? 

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What goals do you have in mind to accomplish while residing at She Brews? 

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How long are you willing to commit to the She Brews Transition Program?

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What is your t-shirt size?

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Have you been working with any She Brews staff member(s)? 

Checkboxes

If so, whom?

Text field

Text field

Text field

 

How did you hear about the She Brews Transition Program?

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Have you read the rules and guidelines required for the She Brews Transition Program?
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Do you agree to abide by the rules for the duration of your stay in the program?
Checkboxes

 

Do you have any major health concerns? Please explain.

Client health problems

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Do you have a diagnosed mental illness? Please explain.

Client diagnosis

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Medical History

Have you ever considered suicide?
  Checkboxes

Have you ever attempted suicide?
  Checkboxes

Do you currently feel suicidal at this time?
  Checkboxes

Are you currently taking any medications?
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Medications

Medication

 

Family Medical History

Do you suffer from:
Checkboxes

If other, specify: Text field

 

Do any family members suffer from:
Checkboxes

If other, specify: Text field

Please list the name(s) and relationship(s) to any affected family members:

Family Members

 

In Case of Emergency

Contact

 

Projected Release Date: Text field

DOC #: Text field

 

I agree to the stated guidelines, rules, and standards of conduct, and declare the above information is true to the best of my knowledge. *

 

Signature: Signature Date: Text field