Transitional Housing Application Name * First Name Last Name Age * Phone * (###) ### #### Email Date of Birth * MM DD YYYY Case Worker or Referred By Case Worker/Reference Contact Info Approximate # of Arrest(s) * List Charges with Dates * List Felonies with Dates * List Pending Cases * Are you on probation? * Yes No If so, what county? Who is your probation officer? Probation officer's phone number (###) ### #### Line Are you a victim of domestic violence? Yes No Are you a victim of sexual abuse? Yes No Have you ever been admitted to a mental health facility? If so, when and what for? * Do you have any mental health diagnoses? What medicines are you currently taking or will need to take while in our program? * Do you have any physical disabilities that would prevent you from being able to work? If so, please explain: * Have you attempted suicide? Yes No Are you a smoker? Yes No Line Substances used in the past: marijuana * Yes No synthetic marijuana * Yes No meth/amphetamines * Yes No narcotics * Yes No hallucinogens * Yes No prescription medications * Yes No alcohol * Yes No opiates/fentanyl * Yes No barbiturates * Yes No benzodiazepines * Yes No Line Highest level of education received: * Employment history- what kinds of jobs have you worked in the past: * What do you want to gain from residency at Angels Charge? * What are your short-term goals? * What are your long-term goals? * Thank you for submitting an application for transitional housing via Angels Charge Ministry. A team member will reach out to you soon.
