Resident Application - Redemption Housing

First Name(Required)

Last Name(Required)

Program of Interest(Required)

Gender(Required)

Email(Required)

Phone(Required)

Preferred Contact Method

Birthplace

Marital Status(Required)

Which of these options is closest to your current faith?(Required)

Describe your religion/faith in your own words:(Required)

What is your highest level of education completed?(Required)

How many times have you been homeless in the past 5 years?(Required)

Describe your physical health:(Required)

Optional explanation of physical health:

Describe your mental/emotional health:(Required)

Optional explanation of mental/emotional health:

Please list any current medications:

What was the primary drug used?

When was the last time you used drugs or alcohol?

Have you ever been in treatment? If so, when and where?

Did you ever successfully complete treatment?

Name of correctional facility:

How much probation tail?

What plans have you put in place for successful reentry?(Required)

What have you done recently to show that you care about your future?(Required)

Describe your long-term goals.(Required)

What job skills do you have?(Required)

Have you completed any certifications or specialty training (prior to or during incarceration)?(Required)

Name and contact information of sponsor/mentor

Name of faith community

Explain learning interests:(Required)

Where did you hear about Redemption Housing, or who referred you?(Required)