Application – Welcome Home Ministries

Step 1 of 4

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Personal Information:

Name*

First Last

Age*

Please enter a number from 1 to 120.

Date of birth*

MM slash DD slash YYYY

Email*

Phone*

Race*

Are you Hispanic or Latino origin?*

Veteran?*

Marital Status*

Current Residence:

Address*

Street Address Address Line 2 City State ZIP Code

How long have you been at current residence?

When must you leave?

Referral Made By:

Name

First Last

Agency Name

Phone

Nearest Living Relative:

Name

First Last

Relationship

Phone

Address

Street Address Address Line 2 City State ZIP Code

Emergency Contact Person:

Name

First Last

Relationship

Phone

Address

Street Address Address Line 2 City State ZIP Code

Medical History:

Medical Background

Please list any medical conditions/disabilities/psychological or psychiatric diagnosis:

Medications

Please list any prescribed medications, dosage and reason for taking:

Documentation

If there are any diagnosed mental or physical disabilities, please upload documentation…this includes treatment for addiction. A doctor or other health professional must sign it.

Drop files here or

Accepted file types: pdf, jpg, jpeg, doc, docx, png, xls, xlsx, Max. file size: 50 MB, Max. files: 5.

Employer:

Employer Name

Supervisor Name

First Last

Phone

Position

Wage

Number of Hours Worked

Work Schedule

Pay Schedule

Highest Level of Education

Did you receive one of the following?

Is English your primary language?

Additional Information:

Do you have a disability of long duration?

Yes

Disability Type:

Alcohol abuse

Mental illness

Drug abuse

Chronic Health condition

HIV/AIDS related condition

Development disability

Physical disability

Are You a Survivor of Domestic Violence in the Last Year?

Time period of Domestic Violence Experienced

Drug/Alcohol Use

Please give a brief case history of the applicant and include the type of drug/alcohol use.

Commitment

Why do you believe the person has made a sincere commitment to change and/or what have they done to improve their situation?

Legal

Is the person currently involved in any legal situations i.e. probation, pending litigation, court ordered requirements, etc?

Probation Officer

(if applicable)

First Last

Probation Officer Phone

Transportation

Does this person have access to transportation other than MTA?

Yes

Transportation – YES

If yes, what type of transportation?

Agency Suggestions

Does the referring agency suggest any follow up or after care procedures?

Yes

Agency Suggestions – YES

If yes, please describe.

Sponsor

Does the applicant have a “sponsor”?

Yes

Sponsor Name

If so, please give name:

First Last

Sponsor Phone

and phone number:

Financial

How much money does the applicant have saved at time of application?

Ability to pay rent

If less than $165.00, does the applicant have ability to pay first week’s rent in advance?

Yes

Additional Income

Does applicant receive any other income such as Social Security, Disability, or other? Explain & give amounts.

Move In Date

What date does the applicant wish to move into the house?

By submitting this application form, applicant agrees this and other related information on this application may be shared with the staff of Welcome Home House.

CONSENT TO ABIDE BY GUIDELINES AND TERMINATION OF SERVICES

I have read the guidelines and understand them. My signature below indicates my willingness to follow these guidelines. I also agree to willingly submit to random drug testing. Refusal to take the test or a positive test will result in dismissal from the house and a forfeit of my $25 drug test deposit. However, if I test negative, my $25.00 drug test deposit will be refunded to me upon successful completion of the program. Furthermore, I agree to pay $165.00 per week, due on Friday of each week to the house manager along with other appropriate paperwork (Meeting sheets, AV sheets, Service Hours, Spending Plan, Employment Form, etc). I understand that failure to comply with any of these guidelines could result in dismissal from this program. Written notice will be given for reason of termination. The participant is given the opportunity to present written or oral objections before senior staff. Prompt written notice of the final decision will be given to the participant. It is also understood that any of my belongings left at the house will be discarded one week from my last day as a resident in the house. I agree to give notice to the house manager of my intentions to move out of the house (preferably two weeks.)

PLEASE READ THE GUIDELINES HERE (OPENS IN NEW WINDOW) BEFORE SIGNING AND SUBMITTING THE APPLICATION.

Consent*

I have read and agree to the guidelines.*

Digital Signature*

Date Signed*

MM slash DD slash YYYY

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