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Contact information
Please fill out the following application for Grace Place. Please answer all questions completely. Admittance is not guaranteed until a clean drug test on move-in day.
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* Required
Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Social Security Number
*
Your answer
Contact Number
*
Your answer
Is this your phone number?
*
Yes
No
Email
*
Your answer
What is your gender?
Female
Male
Client doesn't know
Client refuses to answer
Other:
Clear selection
What is your ethnicity?
American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
White/European Descent
Unknown
Other:
Clear selection
What services are you seeking? (Choose all that apply)
*
Emergency Shelter
Long-term Shelter
A&D Services
DV Services
Job Training
Other:
Required
Have you stayed at Grace Place before?
*
Yes
No
Where are you currently staying?
*
Your answer
Are you at eminent risk of harming yourself or someone else?
*
Yes
No
Are you willing to submit to a 12-month program?
*
Yes
No
Initially, there are no privileges available. This includes phone calls, visitations and free time. Are you willing to submit to significant restrictions in the initial phases of the program?
*
Yes
No
Are you currently pregnant?
*
Yes
No
Not Sure
Are you on probation or parole?
*
Yes
No
If yes to question above, which county?
Your answer
Name of Probation Officer
Your answer
How often are you required to report, and where?
Your answer
Please list any upcoming court dates.
*
Your answer
List any current charges, legal issues or warrants.
*
Your answer
Do you have children?
*
Yes
No
If yes, list their first names and ages.
Your answer
Who has custody of your children?
Your answer
Is DCBS/CPS involved?
Yes
No
Clear selection
Who currently cares for your children?
Your answer
Who will care for your children if you are at Grace Place for 12 months?
Your answer
Are you a victim of domestic violence?
*
Yes
No
What is the name of your abuser?
Your answer
What is your abuser's relationship to you?
Your answer
Do you need law enforcement or medical attention?
Yes
No
Clear selection
Do you have substance abuse with: (Check all that apply)
*
Alcohol
Marijuana
Cocaine/Crack
Heroin
Barbituates/Pills
Amphetamines
Methamphetamine
Other:
Required
List the date(s) of last drug use?
Your answer
How many overdoses have you had?
Your answer
What are the dates of your overdoses:
Your answer
What are the dates and locations of your past treatments?
Your answer
Do you experience any of the following?
*
Depression
Anxiety
Hallucinations
Flashbacks
Violent Tendencies
"Voices"
Other
Required
What treatments are you currently receiving for any of the above?
Your answer
List all medications.
*
Your answer
Do you have any health problems or limitations?
*
Your answer
Are you able to climb a flight of stairs?
*
Yes
No
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