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Magdalene House OKC Resident Application
PLEASE READ BEFORE COMPLETING APPLICATION. After submitting application, a member of program staff will reach out regarding the next steps. Please note, a minimum period of sobriety of no less than 60 days is required to be considered for admittance. Additionally, we will be unable to complete interviews or extend offers of invitation into the home if you have been committed of a violent crime and/or are required to register for the Mary Rippy Violent Offender Registry. 
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Last Name, First Name, MI *
Date of Application  *
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Best Method to Contact - please include number or email *
DOB *
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Referring Agency  *
Probation/Parole Officer Information (include name & Phone #) *
Estimated Release Date *
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Do you have any children?  *
Do you have any children under 18 years of age? *
Are any in the custody of DHS? *
If not in DHS custody, who has primary custody? *
Check type of and/or alcohol preference: *
Required
Age you began using drugs/alcohol:  *
Last time you used drugs/alcohol: *
What is the longest period of sobriety:  *
Do you have any physical disabilities or limitations? *
If yes, please describe:  *
Do you currently take any medications?  *
If so, please describe:  *
Have you ever received a metal health evaluation?  *
If yes, what were the results?  *
Have you ever received any of the following services? *
Required
If yes, please describe:  *
Can you tell us about your employment history? *
What is your highest level of education?  *
Do you have any of these prior convictions? 
Other violent charges? 
Do you have any felonies? If so, please explain:  *
Do you have any pending charges? If so, please explain *
What goals would you like to achieve while in the program? *
What other programs have you explored or completed? *
What worked well for you in those programs?  *
What was not helpful for you, or what did not work well? *
If applicable, what caused you to relapse or reoffend, in the past? *
What do safe boundaries look like to you? *
Magdalene House OKC is a community, what does living in a community look like for you? *
How do you handle conflict with others? *
What questions do you have for us? *
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