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Grace House Housing Application
Hey! We are so glad you found us! Grace House is a one year transformational program. We take mothers in who are in crisis. We value Christian beliefs and will attend church weekly. Being a larger facility, there are rules to follow and this is a drug free home. We will work our best to give you EVERY resource in our power so that you walk out of Grace House with tools you need to succeed and make it on your own. If you need an education, drivers license, or any assistance we will help you attain your goals.  You will meet with counselors to help you overcome life's troubles that you have faced. Most importantly - you will learn the word of God. If you feel like this sounds like something you might want more information on then please take some time to fill this out!
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Name *
First and last name
Email address
Phone number *
What is your Date of Birth? *
Emergency Contact Name & Phone Number *
What is your story *
Where are you currently living? *
How many children do you have? What are their ages? Please explain any custody arrangements. *
Are you currently pregnant? How far along? *
What age were you when you had your children? *
Marital Status *
Do you have your social security card? *
Do you have a valid Drivers License? If yes, please list the State and the DL Number. *
Do you have insurance? If yes, please list what kind *
What are your educational goals? *
Are you currently enrolled in school? If so where? *
What is your previous work experience *
Have you ever been diagnosed with any Psychiatric disorders? Please explain. *
Have you ever attempted suicide? *
Are you on any kind of medicine? If so please list with the name and location of the prescribing physician: *
Do you smoke, vape, or use any other tobacco products? If so, what do you use and how often? *
Do you drink alcohol or use any illicit drugs? If yes, what do you use and how often? When was the last time you used?
*Please note- withholding this information may lead to being asked to leave the program. Answering yes to these questions will not keep you from entering the program; we are just trying to gauge your needs.
 *
Have you had any convictions or served time for a crime you committed? If yes, please explain. *
Do you have any pending legal issues or warrants? If so, please explain. *
Are you willing to commit to our one year faith based program? *
What is your relationship with God? *
It is important that all of the questions are answered truthfully so that we can know what your needs are. This information will NOT be shared with anyone.

Will you confirm that you answered all of the questions honestly?
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Today's Date *
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How did you hear about Grace House? *
Any additional information you would like us to know?
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