The Glory House for Women

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Home
About Us
Our Program
Contact Us
Get Involved
Program Application

Program Application

Name

SPN or TDOC#

SS#:

Date of Birth

Age

Projected Out Date/Court Date:

Ethnicity

Institution

Unit

What program are you in, if any?

Who is your current case manager?

How many times have you been incarcerated?

How many times have you been arrested?

List all convictions:

Year

Charge

Year

Charge

Year

Charge

Year

Charge

Year

Charge

Year

Charge

Have you ever been arrested for causing bodily injury to anyone?

If yes, please explain:

FAMILY:

Current Marital Status

married divorced separated widowed single Common Law

Do you have children under the age of 18?

Yes No

How many male?

How many female?

Do you have any children 18 or older?

Yes No

How many female?

How many male?

Do you have any open CPS cases?

Do you have any "injury to a child" convictions ?

Yes No

Please Explain In Detail?

Who has custody of the children - Who is taking care of the children?

is reunification with your children part of your plan?

Yes No

MEDICAL

What are your medical and psychological needs, if any?

Please list medications you are currently taking:

Medication

Dose

Medication

Dose

Medication

Dose

Have you ever been hospitalized for physical or mental health issues?

If yes, please explain when and where:

SUBSTANCE ABUSE HISTORY:

Have you ever used alcohol or drugs?

Yes No

Please identify/circle:

Alcohol Marijuana Cocaine Crack Heroin Prescriptions Methamphetamine PCP

What is your drug of choice?

Have you ever completed a substance abuse program?

Yes No

Please list program & dates:

Program

Date

Program

Date

Program

Date

EDUCATION HISTORY

High School Grad

GED

College

Last grade completed:

Did you attend school while imprisoned? If yes, what classes were you enrolled in?

Have you participated in any programs during your past incarceration/s?

Yes No

please list program and date:

Program

Date

Program

Date

Program

Date

EMPLOYMENT/INCOME:

Last year and place of employment:

Have you ever received SSI and/or SSDI, if so, when?

GOALS:

Why do you want to come to The Glory House for Women?

List your short term goals (six months to one year after your release.)

1

2

3

4

What are your strengths?

What are your areas of growth?

What do you like most about yourself?

What would you like to change or improve?

How do you motivate yourself?

SELECT THE SERVICES BELOW IN WHICH YOU WANT SUPPORT:

Substance Abuse Recovery Support

Yes No

Mental Health Services

Yes No

Legal Aid

Yes No

Education

Yes No

Workforce Development & Employment

Yes No

Parenting

Yes No

Domestic Violence Recovery

Yes No

Healthcare Navigation

Yes No

Entrepreneurship

Yes No

Anger Management

Yes No

Transitional Housing

Yes No

Other:

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731-612-4460

hsbonds@gloryhouse731.org

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