DISMAS HOUSE APPLICATION

Name:
                                   (Last, First, Middle)

Number:  
Institution:

Birth Date:  (mm/dd/yyyy)
Birth Place:

Social Security #             Driver's License?

Last Residence:
 

Whose address is this?

Name:

Relationship:

Address:
 

Telephone:

One other person who will always know how to contact you?
 Name:

Relationship:
Phone:         

What are your financial obligations?
 

Economic Resources?
 

Marital Status:
Married how many times?

Number and ages of children?
 

In regular contact with spouse or significant other?

Kids?               
Parents/Family?
Other?

Have you ever been diagnosed for any health problem?
 

If so, list and give treatment received:
 

Are there any other health problems that would prevent you from working?
 

Describe your mental health history:
 

Treatment received:
 

Do you believe you have/had a drug or alcohol problem?
 

Are you an alcoholic and/or drug addict?
 

List primary drugs of use, method of intake, and age of first use:

1.

2.

3.

What treatment have you received?
 

Education:
 

GED:
                             (last grade completed)

Place and Date:
 

College/Trade School:
 
                    (place, hours completed, degree sought)

Military Service?
 

Combat Experience?
 

Years of service:

Type of discharge?

Company:

Address:

From:     To:

Why did you leave?

Describe job (tasks):
 

Were you employed at time of most recent arrest?
 

How many freeworld jobs in last 3 years before arrest?
 

What is the longest time you've held the same job?
 

What are you future employment plans?
 

CURRENT CHARGES:
 

CURRENT CONVICTIONS:
 

Alcohol/drugs prior to (or during) crime?
 

Current sentence?

Date incarcerated, this offense:

Did you know the victim?

How?

Plea bargain/agreement?

Expiration of sentence date: (mm/dd/yyyy)

Have you met the parole board on these charges?

How many times?

Next parole hearing? (mm/dd/yyyy

Earliest release date: (mm/dd/yyyy

List all disciplinaries:
 

How long since last one?
 

Prison Job:

Prison Programs:
 

Prison Employee, Volunteer, or other Community References:
Name                                      Position                           Phone #          # of years known
           
           
           

Who is your counselor of caseworker?

Your age at first arrest?

Juvenile record? (list all arrests and convictions)
 
In Juvenile facilities?     How long?

Prior ADULT arrests, charges?
 

Prior ADULT convictions:
 

How much of your adult life has been in prison/jail?
 

Have you ever applied to/lived in a Dismas House?
Which one?

Hobbies:
 

Personal Goals:
 

I agree to stay at Dismas House for 90 days.  I will follow the program as described in the fact sheet.  I give permission for Dismas to see any information in files kept on me by the Dept. of Corrections or by any other agency.  I understand this information will be kept confidential by Dismas.  Ten days after termination of my stay at Dismas house, the staff will dispose of any property left unless I have a name and address of person to be notified.

DATE: (mm/dd/yyyy)