Gwen's House Application
Initial Screening Application for Gwen's House
Please click the link on our website www.gwenshouseoh.com  to submit or mail to Gwens  House PO Box 2855 North Canton, OH 44720
Or if you are currently incarcerated please see your chaplain, case manager or an employee to submit to us through email at info@gwenshouseoh.com      330-267-9283
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Full Name ( include maiden name and aliases ) *
Who referred you? *
Date *
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Is your release within the next 4mos?  If no, do you understand that you will need to resubmit app when you are closer to release time?  *
Address ( current facility ) *
Best way to contact you (phone, email, case worker?) *
Emergency Contact Info (family, friends, etc) *
Do you have a Power of Attorney established to make decisions for you medically or financially in an emergent situation?  *
Are you planning to leave incarceration on Vivitrol or any other MAT?  If yes, explain. *
What county sanctioned you to incarceration? *
DOB *
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Last 4 of social *
 Out Date *
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Type of release *
Length of Time incarcerated (applicant must have been incarcerated minimum 1 year consecutive) *
Date of incarceration *
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Tell me your story, why are you incarcerated? *
What are your charges currently? *
What have you been charged with in the past, list charges and dates?  Have you EVER been charged with a violent and/ or sexual offense? *
How long have you used drugs / alcohol? *
Drug (s) of choice ? *
 Does your family use drugs?  Elaborate *
 How long have you been sober?  (applicant must be sober minimum 6 months) *
Sobriety Date *
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How do you plan to stay sober? *
Do you have a sober support network?  Do you have a sponsor?  Name and # *
Are you currently employed?  If yes, where and for how long?   *
What do you plan to do for employment upon release?   *
How do you plan on managing your money?  Are you willing to follow a budget and be accountable with all of your money? *
How do you plan to spend your time?  Are you willing to allow Gwens to help you set a healthy schedule and then you follow it? *
Have you ever been evicted?  What were the circumstances? *
What is your plan for transportation to get to work, meetings, church, appointments etc? *
Tell me about your faith.  What do you believe about God? *
Do you have a home church?  Do you have a pastor? *
Do you go to church, 12-Step or other meetings, or other social groups?  What do you do with your free time? *
Do you have tickets?  Have you been to RIB?  Tell me about your behavior while incarcerated. *
Are you on probation or parole?  For how long? *
Do you have any medical diagnosis'?  Are you are being treated for anything? *
Do you have any mental health diagnosis ?  Or any MH concerns?   *
Are you on medication?  If yes, please list all medications. *
Are you married, single, dating ? Do you have children? *
What relatives do you currently have contact with? *
How long do you plan to need housing?  What is your transitional time frame? *
How would you rate your motivation level? *
barely motivated
super motivated
How much supervision do you need to be able to stay on track *
Requiring no supervision
Need lots of supervision
What people might trigger you to use?  What places did you use? *
Name all the people that are good for you that you want to keep in your life. *
What are your expectations of Gwen's House?  What do you need help with? *
What are your goals?  Short term and long term *
What's your biggest fear? *
What did you learn from incarceration?   *
Name 3 references (chaplain, case manager, mental health liason, officer etc.)  one can be a sober family member.  Give me full names and # so that I can contact them.   *
Tell me why you should be selected as a client at Gwen's House? *
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