Residency Application

PERSONAL INFORMATION

First/Last Name:

Best phone number to reach you at:

Email (if you have one):

Date of Birth:

Your Age:

Address of where you’re currently staying (if applicable):

What city were you living in before coming to The Gospel TLC, and why do you want to leave that place?

Please list the different types of help that you need:

Why do you want to live at Gospel TLC?

Have you been homeless before (including couch surfing and staying with other people)?

Yes

No

How long have you been homeless before?

Are you on the ankle bracelet?

Yes

No

What is your highest level of education that you have completed:

Did you have a diagnosed learning disability in school?

Yes

No

Marital status:

Married

Divorced

Never Married

Are you currently in relationship with a:

Girlfriend

Boyfriend

Engaged

None

Do you have any biological children?

Yes

No

How many children do you have, what are their ages, where do they live, and what are your custody rights to them?

Do you still owe child support?

Yes

No

How much do you owe a month?

Your father’s full name:

Is he deceased?

Yes

No

Where does he live, and what is your relationship like with him?

Your mother’s full name:

Is she deceased?

Yes

No

Where does she live, and what is your relationship like with her?

Are your parents divorced?

Yes

No

How many siblings do you have, and what is your relationship like with them?

Are you a convicted felon?

Yes

No

What are your felony convictions and the dates of each conviction?

Have you been incarcerated before?

Yes

No

When was your last release date?

What have you been incarcerated for?

Do you have any “Open Case(s)?”

Yes

No

Are you on probation?

Yes

No

PO Officers Name & Phone Number:

Are you a registered sex offender?

Yes

No

Do you have a valid driver’s license?

Yes

No

Do you have medical insurance?

Yes

No

Do you have any current medical issues that our staff needs to know about for your safety and wellbeing?

Yes

No

Are you currently taking any doctor prescribed medications?

Yes

No

If yes, please explain the medical conditions.

Do you have a DIAGNOSED disability?

Yes

No

What diagnosis?

What is the name of the medication(s), and what is it used for?

Do you have a bank account?

Yes

No

Are you currently attending any counseling services in the community?

Yes

No

SPIRITUALITY

If you are a Christian, what church do you currently attend or have last attended? Please provide the name of the church, the city and state, the pastor's name, and the last time you attended.

DRUG & SUBSTANCE ABUSE HISTORY

What drugs/chemicals have you used in the past:

At what age did you start to experiment with drugs, alcohol, sex, criminal activity, or anything else not listed?

What was your last date of relapse, and what did you relapse on?

What is your drug of choice, what are your triggers for relapse, and who do you use with?

How have you tried to stay sober in the past, and what’s the longest you have maintained sobriety?

Have you ever overdosed before?

Yes

No

What have you overdosed on, and when was your last overdose?

Have you been to a detox facility before?

Yes

No

How many times, where was it located, when did it occur, and what was the experience like?

Have you been to drug treatment centers before?

Yes

No

Where and when did this occur, and what drug issues did you address?

Do you currently have a sponsor?

Yes

No

WORK HISTORY

Do you currently have a job?

Yes

No

IF YOU ARE ADMITTED INTO OUR PROGRAM, YOU WILL NOT BE PERMITTED TO HOLD A JOB FOR A MINIMUM OF ONE YEAR. LATER IN THE PROGRAM WE WILL HELP YOU TO GET A JOB.

REFERENCES

Who are three people that know you that we should talk to so we can find out more information about you? (friend, family member, co-worker, former supervisor, probation officer, pastor, etc.)

Person #1: Who is this person to you, how long have you known them, and what is their phone number?

Person #2: Who is this person to you, how long have you known them, and what is their phone number?

Person #3: Who is this person to you, how long have you known them, and what is their phone number?

PROGRAM COST

Do you have a monthly source of financial income?

Yes

No

How much a month?

Do you have people (family, friends, church, etc.) in your life that can help pay for your program cost?

Yes

No

YOUR TRANSFORMATION

Please explain in the space below why you should be admitted into our program?

List 3 specific goals that you have to transform your life:

I have read the above information, understand and agree to the program requirements.

Print Name:

Date:

Signature

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Did someone help you to fill out this application? First and last name of person and their position or title of their organization:

Your application will be reviewed, and you will be contacted when space becomes available. If you have any questions in the meantime, please don’t hesitate to email info@gospeltlcwi.org or call 715-212-1868.