Application Form

Resident's Profile

Name:__________________________________________Age:____Sex:____Date:____

Last First M.

Permanent Address:_______________________________________Phone: ( )_______

City:_____________________________________State:____________Zip:___________

S.S.#_____-___-____ Date of Birth:________________

Hair Color:______ Eyes:______ Height:______ Weight:__________________________

In case of an emergency notify:______________________________________________

Name Relationship

Address City State Zip Phone #

Are you an American citizen? ( ) yes ( ) no Race:____________________

Who referred you to Jackie’s House?__________________________________________

HEALTH

Do you have any physical problems?__________________________________________

Are you a diabetic? ( ) yes ( ) no. Do you require a special diet?____________________

Do you have any food allergies? ( ) yes ( ) no. What foods?________________________

Do you have any allergies of medication? ( ) yes ( ) no. Which ones?________________

Are you subject to seizures of any kind? ( ) yes ( ) no._____________________________

Explain if yes:____________________________________________________________

Have you ever had psychiatric care or test? ( ) yes ( ) no.__________________________

Explain if yes:____________________________________________________________

Are you currently on any medication? ( ) yes ( ) no.______________________________

If yes please list meds:_____________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ARREST RECORD

Date:___________Where:_____________Charge:________Disposition of Case:_______

Were you convicted: ( )yes ( )no. Sentence:________________________________

If there is any more, list them on the back of this paper in like manner. If Jackie’s House is part of your sentence, please attach court order to this document.

Case Pending:__________________________________Date:______________________

Lawyer’s Name:___________________________________Phone:__________________

Case Worker’s Name:________________________________ Phone: _______________

List any Institutions where you have been a resident: (including prisons, jails, psychiatric wards, rehab programs, etc.

Name of Institution:_______________________________________________________

Date Entered:___________ Reason:___________________________________________

Results:_________________________________________________________________

If there are additional Institutions please list below:

For inmates presently incarcerated in prison/jail

Name of Institution:_________________________________Institution #_____________

Social Worker’s Name:_____________________________________________________

Are you eligible for: Probation ( ) yes ( ) no Parole ( ) yes ( ) no

When do you appear before the board?____________________Is this your first time____

Have you received parole? ( ) yes ( )no Have you received probation? ( ) yes ( ) no

MILITARY SERVICE HISTORY

Have you ever been in the military: ( ) yes ( ) no From:____________to___________

Which branch of service were you in?_________________________________________

What type of discharge did you receive? ( ) Honorable ( ) Dishonorable ( ) Other_______

EMPLOYMENT HISTORY

Were you ever employed full time? ( ) yes ( ) no From:_____________to____________

Please list you work skills:__________________________________________________

What was your last occupation?______________________________________________

Name of Employer:________________________________________________________

Address:_________________________City:________________________State_______

Job Description:______________________________From:__________to____________

Reason for leaving________________________________________________________

What kind of work do you enjoy doing?_______________________________________

FINANCIAL STATUS

Do you have any financial situations that would prevent you from completing the program? ( ) yes ( ) no. Explain:______________________________________________

Do you have anyone who can help to cover expenses at Jackie’s House? ( ) yes ( ) no.

If Yes, please give names, contact information, and how much they can support you:

EDUCATION

High School Attended:___________________________City/State__________________

Grade Completed:__________________Year:_____________Degree:_______________

College:____________________________________________State:________________

Years Completed:______________Year:______________Degree:__________________

Other Training:_________________________________City/State__________________

What is your level of reading and writing ( ) Good ( ) Fair ( ) Poor

Do you have your G.E.D.? ( ) yes ( ) no

If you were raised by anyone other than your natural parents, briefly explain:__________

Father’s Name:________________________________Phone #_____________________

Address:________________________________City:__________State:______Zip_____

Occupation:______________________________________________________________

Mother’s Name:_______________________________Phone #_____________________

Address:________________________________City:_________State:______Zip______

Occupation:______________________________________________________________

How many brother’s do you have?_______Sisters________________________________

RELIGIOUS BACKGROUND

Does your family attend church? ( ) yes ( ) no Name of church?____________________

Do you attend church? ( ) yes ( ) no

Name of church:______________________________City/State____________________

Pastor’s Name:_______________________________Phone #______________________

Are you a Christian? ( ) yes ( ) no.

Have you invited Jesus Christ to be Lord over your life? ( ) yes ( ) no

Would you like to turn your life over to Jesus Christ? ( ) yes ( )no

Do you believe Jesus is the Son of God? ( ) yes ( ) no

In your words, what can we do to help you in your situation?

What are some of the characteristics in your life you would like to change or eliminate?

What are you reasons for coming to Jackie’s House? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are there any questions about the Jackie’s House Program? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What is the most important personal goal you have in mind to accomplish by the end of the program? ____________________________________________________________

PERSONAL INFORMATION

This Application Must Be Filled Out Completely

Name:__________________________________________________________________

Last & Maiden First Initial

Address:________________________________________________________________

Street City/State Zip

Telephone:______________________________________________________________

(Home) (Work) (Cell)

Social Security #:_______________________ Drivers License #:_____________

Birth Date:________________________ Age:___________

Marital Status: (Please Circle) Single Married Separated Divorced Widowed

FAMILY INFORMATION

Mother:__________________________ Father:_______________________________

Address:_________________________ Address:______________________________

__________________________ ______________________________

Telephone:________________________ Telephone:___________________________

Other Phone:_______________________ Other Phone:_________________________

Parents Marital Status: (Please Circle) Single Married Separated Divorced Widowed

Spouses Name (if applicable):_______________________________________________

Spouses Address:_________________________________________________________

Street City/State Zip

Spouses Telephone:_______________________________________________________

(Home) (Work) (Cell)

How long have you been married?____________________________________________

Have you ever been separated?_______________ Have you ever been divorced?_____

If widowed, cause and date of spouse’s death:_________________________________

Do you have children?___________________ If yes, how many?__________________

Name Sex Date of Birth & Age

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

If minors, where will each of your children be staying while you are at Jackie’s House? (Include contact persons name, address and telephone number).

NAME____________________________________________________

JACKIE’S HOUSE INC.

CONTACT LIST

(Only people on this list are contacts for phone calls and visits)

Name__________________Relationship________Address_____________Phone #_____

Name__________________Relationship________Address_____________Phone#_____

All names on this list subject to confirmation by staff members.

List approved by:______________________________________ Date:_______________

Residents Physical Form

ATTENTION PHYSICIANS, THERE IS NO SMOKING AT JACKIE’S HOUSE

To be filled out completely by the physician

____________________has applied for admission to Jackie’s House. The following information needs to be completed by the physician.

PHYSICAL EXAM

D.O.B._________ Height_________ Weight_____________

Blood Pressure________________ Temperature________

Heart_______________ Lungs__________ Dental__________

Eye, Ear, Nose & Throat_______________________________

Contagious Skin Disorders_____________________________

Head Lice__________________________________________

MEDICATIONS

Current Medications: __________________________________

___________________________________________________

Any known allergies to medicine? Yes ( ) No ( )

Please list allergies if known: ___________________________

LAB TEST RESULTS

HIV_____________ TBT______________ VDRL__________

Hepatitis A________ Hepatitis B_________ Hepatitis C______

Pregnant__________ Last Menstrual Period_________ Pap Smear

DIAGNOSIS

Please state any restrictions of physical activity, any known present illnesses, required medication, etc.

__________________________________________________________________________________________________________________________

Physician’s Signature__________________________ Date____________

Location of Practice____________________________Phone___________

PLEASE RETURN THIS FORM WITH THE RESULTS OF ALL THE TESTS TO JACKIE’S HOUSE.

RESIDENTS AGREEMENT

I,__________________________agree to abide by all the house rules pertaining to Jackie’s House Inc. which are as follow

_I understand that I will not be denied entrance into Jackie’s House solely on the basis of race, color, religion, sexual preference, national origin, or the fact that I have been denied or terminated by another treatment program.

_I understand Jackie’s House is a six month - one year faith based program that I am expected to complete.

_I understand I am not allowed to fight, argue, smoke, use bad language, or gestures, use drugs or alcohol, or brag about my past street life during enrollment in this program. I will live at Jackie’s House as a member of a family and will conduct myself accordingly, following all house rules and instructions given by staff and other Jackie’s House authorities.

_I understand I will focus solely on my recovery during my enrollment at Jackie’s House. Therefore I agree to let go of any relationships (opposite or same sex) and will not initiate or develop any new ones while attending this program. (If you are married please provide your marriage certificate).

_I understand I am not allowed any radios, recorders, or tape players, DVD players, MP3-IPOD,or TV’s during my stay at Jackie’s House unless the House Manager allows such equipment in my possession.

_I understand I will keep myself neat and clean while following all dress codes and personal hygiene rules. (Only one shower per day is allowed). I will keep my room neat and clean at all times, this includes my bed, closet, dresser and floor area.

_I understand I am allowed to follow a pre-approved list pertaining to phone calls, mail, and visitors.

_I understand that my mail, both coming in and out, will be read with a House Manager until the privilege of privacy is given. Residents on discipline will not receive mail until discipline has ended.

_I understand I will be able to schedule and receive visits from a pre-approved list every other Saturday or Sunday between 2:00pm and 5:00pm after my (30) day probation, pending approval of the House Manager.

_ I understand I am expected to participate in and at all Church Activities and outreach that have to do with Jackie’s House.

__I understand there is no smoking at any time at Jackie’s House or anywhere else while enrolled in the program. This includes the house, grounds, the streets, the store, church, any programs I attend.

__I understand that there will be random searches of my personal belongings

__I understand that when I get a job, 60% of what I make will return to the house to cover expenses the house has. I also understand that the staff will help me to manage my money.

__I understand that I am representing Jackie’s House whenever I am out and will respect all the rules and regulations set before me regardless of where I am.

_I understand I am not allowed to leave the property of Jackie’s House, Church Events, or Promo drops, unless otherwise given permission by an authorized staff member. I understand that if I choose to leave or if I am dismissed from this program, I will not contact any other resident or unauthorized staff member. If I am given permission to leave for a specific reason, I am to conduct myself with integrity. If the staff supervisor knows or sees otherwise, I may be and can be terminated from this program.

_I understand that Jackie’s House is based on the Word of God and that the discipleship format may not agree with my secular views. However I understand that for positive results in my recovery, my discipleship depends upon my efforts to apply the Word of God to my life and not to lean on my own understanding, while enrolled in this program.

Resident:___________________________________________Date_________________

Case Manager:_______________________________________Date_________________

Program Director:____________________________________Date_________________