Application for Yeshua's House
Tell us about yourself to determine eligibility for our program. You must use numbers only (no letters) in the phone number fields. If you receive a technical issue error message when you try to submit your application, refresh the page and try again. You can also try clearing the cache, using a different browser, or using incognito mode.
Full Name
Age
Housing Requested
Single
Family
Marital Status
Single
Married
Separated
Divorced
Widowed
Referred by:
Enter your phone number
Enter your email
Enter your address
Starting date at current address
Landlord/Contact Person
Landlord/Contact Phone Number
Enter your previous address
How long at previous address?
Landlord/Contact Person
Landlord/Contact Phone Number
Child's Information: Enter the following information for each child to reside in the home with you. Be sure to include Full Name, M or F, and DOB for each child.
Are the above named children legally in your custody?
Yes
No
If no, please explain
Are you pregnant?
Yes
No
If yes, how many months?
List current prescription medications you use and dosage. Please explain the reason for taking medication(s). If none, enter N/A
Do you have a history of any of the following? Check all that apply.
Depression or Withdrawal
Anxiety
Mood Swings
Suicide Attempts
Paranoia
Hallucinations
Restlessness or Hyperactivity
Inappropriate/Sexual Offense Activity
Substance Abuse History
N/A
If you have a substance abuse history, please enter the number of years of chemical abuse, amount of time clean/sober, sobriety date, and substance used.
If you are homeless, check any that apply.
Eviction
Domestic Violence
Loss of job
Incarceration
Debts
Arrests
Substance abuse
Abandoned
Pregnancy
Property damage
N/A
What is your current living situation?
Have you pursued other housing options?
Yes
No
If yes, please explain.
Any past residential placements?
Reason for discharge from last residential placement:
You must agree to a background check. Have you ever been convicted of a felony charge?
Yes
No
If yes, please explain.
Have you ever been convicted of a misdemeanor?
Yes
No
If yes, please explain.
Have you ever been arrested?
Yes
No
If yes, please explain.
Have you ever been convicted of a sexual offense?
Yes
No
If yes, please explain.
Do you have any pending court dates for any reason?
Yes
No
If yes, please explain.
Are you currently or have you ever been on parole or probation?
Yes
No
If yes, please explain
Probation or Parole Officer's Name and Phone Number
Do you have any outstanding warrants for your arrest?
Yes
No
If yes, please explain.
Are you currently employed?
Full time
Part time
No
Current Employer
Start date/End date:
Position and Salary
Current Employer Address
Supervisor's contact number
Previous Employer (1)
Start date/End date:
Position and Salary
Reason for leaving
Previous Employer Address
Supervisor's contact number/May we contact this employer?
Previous Employer (2)
Start date/End date:
Position and Salary
Reason for leaving
Previous Employer Address
Supervisor's contact number/May we contact this employer?
Previous Employer (3)
Start date/End date:
Position and Salary
Reason for leaving
Previous Employer Address
Supervisor's contact number/May we contact this employer?
Please list all sources of income: Please include Agency Name, Type, $ Amount, Frequency, Temporary or Permanent, along with any additional information. Proof of income to be submitted by email to yeshuashouse2refuge@gmail.com.
Please list 2 references: Persons who have known you for at least five years. Do not include former landlords, current employer, counselor, social worker, or a family member. Let them know they will be called.
Reference #1 Phone Number
Reference #1 Address
Reference #2 Phone Number
Reference #2 Address
By electronically signing this document, you certify that the information presented in this document is true; you understand that any false information given is grounds for dismissal from Yeshua's House; and you agree to a background check.
Your Signature
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