Application for Residential Program

Personal and Family Information

Full Legal Name *

First

Middle

Last

Maiden or Other Names Used

Date of Birth *

Age *

Email *

Confirm Email

Phone Number *

Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact *

First

Last

Relationship to Emergency Contact *

Emergency Contact Phone Number *

Marital Status: *

Married
Single
Separated
Divorced
Widowed

Spouse's Name *

First

Last

Spouse Phone Number *

Spouse's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Do you have any children? *

Child 1 Name

First

Last

Child 1 Age

Child 1 Gender

Child 2 Name

First

Last

Child 2 Age

Child 2 Gender

Child 3 Name

First

Last

Child 3 Age

Child 3 Gender

Child 4 Name

First

Last

Child 4 Age

Child 4 Gender

Additional Children

If you have additional children, please list their names, ages, and genders here.

Who is taking care of your children right now?

Are you currently pregnant? *

Will you be willing to participate in this program even though your children will not be able to live with you? *

Do you have a valid driver's license? *

Do you own a car? *

Program Interest

How did you hear about our program? *

Why do you want to be a part of our program? *

Why is now a good time in your life to be a part of our program? *

What is your religious affiliation? *

Christianity
Islam
Judaism
Buddhism
Hinduism
Atheism
Agnosticism
None
Other

Other

If you selected other, please describe your religious affiliation.

Place of Grace is a faith-based organization that follows Christian practices. You do not have to be a Christian to participate in our program, but we do have specific expectations for our program participants that are built on the Christian faith. Will you be willing to participate in these areas of the program? *

Do you currently have a faith community? *

If yes, where? *

What areas do you need support with in order to live a lifestyle of recovery? Select all that apply: *

Education/Literacy
Career
Life Skills
Addictions Counseling
Parenting Skills
Healthy Relationships
Financial Skills
Mental Health
Other

If Other, please describe. *

What are some of the things that cause stress in your life? *

What are some of your strengths? *

What are some of your weaknesses? *

What are some of your passions? *

What are some of your goals? Be specific. *

Incarceration

Are you currently incarcerated? *

If yes, where? *

When are you scheduled to be released? *

What is your current conviction or charge? *

What city/town were you living in prior to incarceration? *

Who were you living with? *

Do you have other housing options for after you are released? *

Please fill out the information below concerning any past incarcerations:

Conviction 1

Beginning Date 1

End Date 1

Location 1

Conviction 2

Beginning Date 2

End Date 2

Location 2

Conviction 3

Beginning Date 3

End Date 3

Location 3

Conviction 4

Beginning Date 4

End Date 4

Location 4

Education and Work Experience

Please list the last 5 places you were employed, starting with the most recent.

What is the highest level of education you have completed?

No degree
GED
High School Diploma
Some College
Associate's Degree
Bachelor's Degree
Master's Degree
PhD

Employer 1

Dates of Employment 1

End Date 1

Employer 2

Dates of Employment 2

End Date 2

Employer 3

Dates of Employment 3

End Date 3

Employer 4

Dates of Employment 4

End Date 4

Employer 5

Dates of Employment 5

End Date 5

What are some of your job skills?

Community Support

Are you willing to work with agencies in our community to improve your recovery skills? *

Are there any agencies that you are unwilling to work with? Which agencies and why? *

If you are selected for the Place of Grace residency program, do you give permission to Place of Grace to obtain records, evaluations, and other confidential information that will be helpful in your recovery journey?

Who are some people who will be supportive and helpful in your recovery journey?

Name *

Relationship *

Name *

Relationship *

Name *

Relationship *

Who are some people who will be harmful to your recovery journey that you need to avoid contact with?

Name *

Relationship *

Name *

Relationship *

Name *

Relationship *

Health

Have you participated in any drug recovery programs in the past? *

If yes, please fill out when and where below:

Program

Beginning Date

End Date

Program

Beginning Date

End Date

Program

Beginning Date

End Date

Please select any of the following that apply to you: *

Alcohol/Substance Abuse
Anxiety
ADD/ADHD
Bipolar Disorder
Depression
Eating Disorder
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Schizophrenia
Autism
Attachment Disorder
Gambling
Other

Please list any physical limitations you have: *

Are you currently taking any medications? *

Please list them *

Do you have any drug allergies or sensitivities? *

Do you currently have Insurance/Medicaid/Medicare/HIP 2.0? *

Please list any dietary restrictions, food allergies, or food sensitivities you have: *

I have filled out this application truthfully and to the best of my ability. I recognize that my failure to complete this application accurately or truthfully could lead to a denied application or immediate dismissal from the Place of Grace residential program. *

Applicant Signature *

Today's Date *

Drug and Alcohol Testing Consent Form

I (name below) agree that at any time, I agree to fully participate in random drug and or alcohol testing, with the understanding that if I do not cooperate fully I am in violation of ministry guidelines and am subject to immediate expulsion from the Place of Grace residential program. I hereby CONSENT to allow a specimen of my hair, urine, or blood and submit it for a scheduled, random, or reasonable suspicion drug test screen. I FURTHER CONSENT to allow the laboratory testing service to make the results of such screen available to the Place of Grace. In consideration for such services being rendered on my behalf, I hereby RELEASE the laboratory testing service, its officers, agents, and employees, from any and all claims which I might otherwise have due to such results being made so available. I hereby CONSENT NOT TO FILE ANY ACTION at law or in equity against Place of Grace, the laboratory testing service, their respective officers, agents or employees in connection with the results of such screen being made so available, and I hereby agree to INDEMNIFY and SAVE HARMLESS Place of Grace, the laboratory testing service, their respective officers, agents, and employees from all damages, expenses, reasonable attorney's fees, and costs of court which they or any of them may suffer or incur, jointly or severally, due to the results of such screen being made so available. *

Applicant Signature *

Today's Date *

Release of Information Form

Name *

First

Last

I have applied to the Place of Grace residential program. As part of the application process, the information below needs to be submitted and reviewed by the leadership before action can be taken on my application. Please submit all information to: Sharon Metzger, Executive Director Place of Grace PO Box 5172, 540 Guilford St Huntington, IN 46750 Place of Grace envisions a Christ-centered community that empowers women to be responsible citizens with a future and a hope. Our mission is to provide a Christian based therapeutic home with long-term recovery services to help women break their cycle of destructive behavior related to addiction, abuse, and poverty

I authorize the release of the following information regarding the above named client: *

Pre-sentence investigation report (PSI)
Department of Corrections File
Conduct Summary
Criminal Files, including Probation, Parole, and Community Corrections
Other (Please describe below)

Paragraph Text *

I authorize that this information may be shared by me, ____________________, and the Review Committee at Place of Grace for the sole purpose of completing my application for acceptance into their Residency Program. All of the information obtained through this release is considered confidential and will be handled in a professional manner. I understand that I may cancel this consent at any time by notifying the staff at Place of Grace in writing, except for information that has already been released. I understand that Place of Grace will not re-release this information to any outside source unless I give my expressed written or verbal consent, or the information has been requested by a valid court order or subpoena. This consent will expire within 360 days from the date signed unless specified here. *

Applicant Signature *

Today's Date *

Residential Program Application

Personal and Family Information

Program Interest

Incarceration

Please fill out the information below concerning any past incarcerations:

Education and Work Experience

Community Support

Who are some people who will be supportive and helpful in your recovery journey?

Who are some people who will be harmful to your recovery journey that you need to avoid contact with?

Health

Drug and Alcohol Testing Consent Form

Release of Information Form

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