Application for Residency

Application for Residency
P.O. Box 700
Monroe, OH 45050
513-423-5433 (P) · 513-423-5150 (F)

Please answer all questions accurately and correctly. Please do not leave any blanks in your application, as this will delay processing. Please write “N/A” or strike through any sections that do not apply. A personal photo MUST ACCOMPANY ALL APPLICATIONS.

Name

Name you go by

Present Address

City

State

Zip

County

Telephone Home

Cell:

Date of Birth:

Age:

Race:

Social Security Number:

- - (optional)

Physical Characteristics:

Height:

Weight:

Eye Color:

Hair Color:

I am currently:

Single Married Separated Living with someone

Do you have any children?

Yes No - If yes, how many?

Highest grade completed

Do you need to work on a GED? Yes No

Have you ever applied for admission to the
Darlene Bishop Home for Life or were you
a previous resident?

Yes No. If yes, when?

Why would you like to come to the Home For Life?

What would you like to see happen in your life during your stay at the Home?

What is the reason that you cannot stay with a family member?

Pregnancy

Are you pregnant?

Yes No. Approximate Due Date

Has a doctor confirmed your pregnancy?

Yes No

Mental Health History

Please check the box(s) below, if you have experienced or been treated for the following:

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Please provide an explanation for any boxes that were checked above:

Medications

Please list current medications AND length of time taken?

Legal History

Have you ever been arrested/incarcerated?

Yes If yes, how many times?

Please explain reason for arrest/incarceration:

Have you ever been convicted for the following (please check all that apply):

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Please provide a brief explanation for any items checked above:

Do you have any pending court dates?

Yes No if yes explain:

Name of Legal Representative

Phone

Judge’s Name

Court

County

Have you ever been on probation or parole?

Yes No. Are you now? Yes No

How long?

Length of time remaining

How often do you report?

In person or through mail?

Name of probation or parole officer

Address

County

Telephone

Chemical Dependency History

Drug(s) of choice used in the last 12 months

At what age did you begin using alcohol/drugs?

How often do you drink alcohol or use drugs?

How long have you realized that drugs and/or alcohol are problematic?

When did you last use?

Alcohol

Drugs

How much do you consume at one time?

Alcohol

Drugs

Do most of your social activities involve drug/alcohol use?

Yes No

Have drugs/alcohol effected your ability to hold a job?

Yes No

Are you presently in treatment?

Yes No Where?

Have you ever been in an alcohol, drug, or detoxification program before?

Yes No (if yes, please list the facilities below)

Name of Facility

Length of Stay

Completed
Yes No

Year

Sources of Income

Welfare

Amt

Social Security

Amt

Child Support/Alimony

Amt

Disability

Amt
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Employment - Employer's Name:

Hrly. Rate

Food Stamps

Amt

Other Income Sources:

Amt

Sponsorship – Please indicate any income that could be used to offset program fees. Individuals/friends/churches

Amt

In completing this application & by initialing after each statement, I acknowledge…

1.	I acknowledge that DBHL is a Christian-based facility and as a result, I will be required to attend church services three times a week, attend prayer meetings, participate in Bible studies and Chapel services.
2	I acknowledge that I must commit to working a highly disciplined spiritual program for the next 9-12 months, once admitted into DBHL’s program.
3	I acknowledge that DBHL does not permit the use of alcohol, drugs or tobacco to be used while in the program. If I am using any of these substances while in the program, I acknowledge that I will be subject to discharge from the program.
4	I acknowledge that DBHL has a strict dress code policy, which requires modesty at all times and I must be appropriately dressed and groomed at all times.
5	I agree to submit to the rules, regulations, and policies of DBHL authorities and am willing to allow Christ to change my life.
6	I acknowledge that DBHL will conduct periodic drug tests/screens and acknowledge that a positive result may result in immediate discharge from DBHL and notification as required by law to my probation/parole officer, if one is assigned.
7	I acknowledge that DBHL is NOT RESPONSIBLE for my medical needs or attention, loss due to theft or transportation to non-program related venues.
8	I hereby authorize DBHL to conduct a police background check.
9	I hereby authorize to talk with individuals who previously provided treatment to me, including, but not limited to, my doctor or former hospitals, clinics, or other health/mental care facilities to discuss any treatment received under their care.

I, , acknowledge that to the best of my knowledge, I have provided true and accurate information in this application. Furthermore, I authorize DBHL to verify the validity of this application and any information contained herein. I further give DBHL staff authorization to communicate with my support network to determine eligibility for admission. I also authorize DBHL to speak with my representation, legal or otherwise, to assist with admission, recovery or aftercare. I understand that any false or misleading information could result in a denial for admission or a discharge from the program.

By signature below, I acknowledge that I have received and read, or have had read to me, the General Release of Liability Agreement, the Housing Agreement, and the Specific Releases Form, as well as received the Darlene Bishop Home for Life Handbook of general rules and regulations. I acknowledge that I have been given the opportunity to review this Application and any and all other agreements relative hereto with legal counsel of my choosing. I further acknowledge that I have executed the General Release Agreement and the Housing Agreement and that I have done so voluntarily and free of any duress, coercion and undue influence.