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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Name *
Date of Birth *
Social Security Number *
Contact Number *
Is this your phone number? *
Email *
What is your gender?
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What is your ethnicity?
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What services are you seeking? (Choose all that apply) *
Have you stayed at Grace Place before? *
Where are you currently staying? *
Are you at eminent risk of harming yourself or someone else? *
Are you willing to submit to a 12-month program? *
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? *
Are you currently pregnant? *
Are you on probation or parole? *
If yes to question above, which county?
Name of Probation Officer
How often are you required to report, and where?
Please list any upcoming court dates. *
List any current charges, legal issues or warrants. *
Do you have children? *
If yes, list their first names and ages.
Who has custody of your children?
Is DCBS/CPS involved?
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Who currently cares for your children?
Who will care for your children if you are at Grace Place for 12 months?
Are you a victim of domestic violence? *
What is the name of your abuser?
What is your abuser's relationship to you?
Do you need law enforcement or medical attention?
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Do you have substance abuse with: (Check all that apply) *
List the date(s) of last drug use?
How many overdoses have you had?
What are the dates of your overdoses:
What are the dates and locations of your past treatments?
Do you experience any of the following? *
What treatments are you currently receiving for any of the above?
List all medications. *
Do you have any health problems or limitations? *
Are you able to climb a flight of stairs? *
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