Doorways Application for Admission


This application form is 8 pages long. Please review the various fields and prepare the information before starting to fill it out.

There is no option to save a partially completed form, but if you keep the tab open on your device, you should be able to return to it.


You will find the following categories:


  • Contact Information
  • Physical Identifiers
  • Personal Information
  • Emergency Contacts
  • Current Living Situation
  • Personal Resources
  • Financial Resources
  • Education
  • Family History & Relationships
  • Legal
  • Substance Use/Abuse
  • Employment History
  • Health
  • References
  • Comments
  • Signatures

 

Contact Information







Physical Identifiers




Race(Optional):

White   Hispanic   Native American   Asian   African American   Other


Personal Information


Marital Status:

Single   Married   Divorced   Widowed


Do you have children?

Yes   No

 


Are you currently pregnant?

Yes   No

 


Are you a US citizen?

Yes   No


Emergency Contacts






Current Living Situation


Describe your current living situation over the last four months (Select all that apply)

Staying with friends   Staying with family   Shelter

Own place   Jail or Prison   With Spouse

On the street   Foster Care   Group Home

Hospital or Treatment Facility   John 3:17




How did you hear about Doorways of Mercy?

Friend/Relative   John 3:17   Newspaper/TV/Media   Support Person



Personal Resources






Is there anyone in your life who could help you achieve your goals?

Yes   No



Do you own any of the following? (Select all that apply)

Driver’s License or State ID#

Health Insurance

Vehicle  If yes, is it insured?

Birth Certificate


Financial Resources



Do you have a bank account?

Yes   No


Do you receive government assistance of any kind?

Yes   No



Education


 

GED

High School:

9   10   11   12

College:

1   2   3   4

Do your future plans include completing any of the following (Select all applicable)






Family History & Relationships


Please describe your relationship with …







Are you in an intimate relationship with someone? (married or not)

Yes   No


Assessment of current relationship:

Good   Fair   Poor


Legal


Have you ever been arrested?

Yes   No



Did you do jail time for the offense?

Yes   No

 


Are your currently incarcerated?

Yes   No

 


Are you on probation or parole?

Yes   No

(If yes, answer questions below)


Have you been or are you currently associated with a gang?

Yes   No


Have you been questioned or charged for physical violence against another person?

Yes   No


Have you ever been convicted of any violent crimes?

Yes   No


Are you a registered sex offender?

Yes   No


Do you have any pending court dates?

Yes   No

If yes, Please fill out the following:



Substance Use/Abuse


Have you ever taken Illegal drugs?

Yes   No

 


Have you recently been to a treatment facility (residential or outpatient)?

Yes   No



Have you ever received a DWI or DUI?

Yes   No

 

 


Have you ever been questioned or charged with the possession or sale of illegal drugs?

Yes   No


We require a drug screening to enter the program.  Do you think you would pass?

Yes   No


Employment History


Please list employment starting with the most recent













Health


Mental Health


Have you ever had counseling or any other form of therapeutic help?

Yes   No

 


Have you ever been treated for wanting to hurt yourself or others?

Yes   No

 


Have you been diagnosed with any form of mental illness/condition?

Yes   No

Examples include schizophrenia, bipolar, depression, anxiety, mood disorders, etc




Are you currently taking medication for this diagnosis?

Yes   No



Are you currently receiving counseling services or care for mental health?

Yes   No


Physical Health


Do you have any food or medical allergies?

Yes   No



Are you taking regular medications (OTC or Prescription)?

Yes   No

Please list all medication you currently take:







Are there any medications you are supposed to be taking but are not?

Yes   No







Do you have any medical conditions that would be important for us to know about?

Yes   No

Examples include diabetes, high blood pressure, heart disease, hepatitis,tuberculosis(TB), infections, etc



Do you think you may be pregnant?

Yes   No

If yes, have you been tested?

Yes   No


Dental Health


 

Are you having any issues with your teeth right now?

Yes   No



References


List three references who are aware of your situation and could verify your need and willingness to work with the program at Doorways of Mercy.


1





2





3





Comments


 


Signatures


I understand an application is not a guarantee of admission and Doorways of Mercy determines applicant eligibility for admission and does not disclose rationale for denial of admission.


By signing below, I acknowledge and understand this application will be used to consider my eligibility to live at Doorways of Mercy.  If accepted, I will sign a conduct covenant, occupancy agreement, and other documents outlining the terms for living at Doorways of Mercy to uphold my safety and the safety of the other residents.  I understand my references will be contacted to verify the honesty of my statements.  I also understand my eligibility will be based on the availability of the space in the units to assist me in my particular needs.  Doorways of Mercy will make a decision based on this application, my interview, and availability of space.  If my statements are found to be falsely represented at any point or I have demonstrated an unwillingness to work within the expectations and terms of my admission, I may be removed from Doorways of Mercy immediately.  I also give permission for Doorways of Mercy to request official documents, make professional inquiries, or complete background checks on me to verify the information I have given them.