SheBrews Application
Today's Date: Date
Estimated Move-In Date: Date
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?
Checkboxes
If not, what is your legal name? Client first nameClient middle nameClient last name
Former Name(s):
Client first nameClient middle nameClient last name
Client first nameClient middle nameClient last name
Client first nameClient middle nameClient last name
Birthdate: Client birthdate
Age: Text field
Sex:
Checkboxes
Marital Status:
Client marital status
Explain Your Current Situation:
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Are you a registered sex offender?
Checkboxes
Facility Name:
Text field
County of Residence:
Dropdown
How would you describe yourself?
Client race
Client ethnicity
Are you a member of a tribe?
Checkboxes
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 Date
Number of children: Text field
What are their situations?
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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?
Checkboxes
What is your t-shirt size?
Checkboxes
Have you been working with any She Brews staff member(s)?
Checkboxes
If so, whom?
Client first nameClient last name
Client first nameClient last name
Client first nameClient last name
How did you hear about the She Brews Transition Program?
Text field
Have you read the rules and guidelines required for the She Brews Transition Program?
Checkboxes
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?
Checkboxes
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
Name of Case Manager: Client first nameClient last name
Phone: Client phone
Email: Client email
Projected Release Date: Client discharge date
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: Date