Q.U.E.E.N.S Butterfly House Intake Application
Email *
Phone Number where you can be reached: 
Name (First, M.I., Last) *
Age *
Date of Birth *
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How did you hear about QBH? *
Are you currently incarcerated? *
If Yes, how long have you been incarcerated
When is your next Court/Parole hearing date?
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What led to your incarceration? *
When is your release date? *
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Do you have any disabilities that would prevent you from walking up and down steps? *
Do you take Doctor prescribed medication? *
If yes, to the above question please list each medication please.
Do you have a history with alcohol or substance abuse? *
If the above question was yes, when was the last time you used?
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Do you have any children? *
If yes to above question, please list name ages and gender below.
Do you need help with child(ren) reunification? *
What are your plans/goals after release? *
How do you plan to accomplish these goals? *
Do you have family support? *
QBH has a $125 deposit which is applied to your first month of rent. Are you able to pay the deposit the day you are accepted/arrive at the home? *
In case of Emergency is there someone we can contact on your behalf? (Name, Number, Relationship)
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