Step 1 of 8 12% Thank you for your interest in applying to Homes for Families. Please read all of the information carefully, including this brief introduction. • Homes for Families exists to provide opportunities for women with children to experience God’s unconditional love, forgiveness and life-transforming power. • Homes for Families is affiliated with STCH Ministries, a faith-based, nonprofit organization. • Homes for Families uses resources and counseling to help women explore issues such as faith, forgiveness, family patterns, overcoming abuse, freedom from oppression and general principles and life skills for life-long success. • Homes for Families uses resources from many different Christian teachers and pastors including: Charles Stanley, David Jeremiah, Neil T. Anderson, Dr’s. Cloud and Townsend and more. Applicants to Homes for Families should have a desire for help in a Christian atmosphere and should be willing to apply the principles of a biblical counseling program. • This application serves to help us determine if we can meet your specific need for help. If for any reason we cannot help, we may be able to refer you to another organization. Please note that we are not a medical facility. • No applicant can be sent to Homes for Families against her will or enter the program without showing a sincere desire to change. Accepted applicants will be asked to sign a Four Month Commitment form prior to entry. • Homes for Families does not charge residents to be a part of the program; however residents are asked to provide their own medical expenses, whether through insurance, sponsorship, governmental benefits or personal contribution.It is the applicant’s responsibility to call the Intake Department at 361.645.3005 to schedule a telephone interview upon completion of this application. All interviews are scheduled in advance. Phone Interview After you submit your application, a Homes for Families staff member will contact you to schedule a phone interview. Your interview will take approximately one hour. Please be sure that you are alone and free to speak at the time scheduled for the phone interview. Application for Acceptance to Homes for Families This information is confidential. The information in this application will not be held against you or used to judge you in any way. Homes For Families is dedicated to helping those who need emotional and spiritual healing and restoration. If for any reason Homes For Families cannot meet your particular need, we may be able to refer you to someone who can. Please answer all questions honestly so we may know how best to help you. Please do not leave any blanks in your application, as this will delay processing.Name* First Last Preferred NamePresent Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone*Work PhoneEmail* How did you hear about Homes for Families?* DHS Court Parents Church Radio/TV Newspaper Internet Have you ever applied to Homes for Families in the past?* Yes No If yes, give approximate date:Does your family support your decision to come to Homes for Families?* Yes No Personal InformationDate of Birth* MM slash DD slash YYYY Age*Ethnicity/Nationality*City, State, and Country of Birthplace*Height*Weight*Eye Color*Hair Color*Marital Status* Single Married Divorced Separated If married, for how long?How many children do you have?*Please list the names, sex and ages of all your children coming to Homes for Families.NameSexAgeGrade Who has custody of your children?*How do your children feel about coming to Homes for Families? (If applicable)*Are you pregnant?* Yes No Approximate Due DateHas a doctor confirmed your pregnancy? Yes No Is the birth father aware of your pregnancy? Yes No What involvement do you anticipate the birth father having with you during your pregnancy?Which are you considering? Parenting Placing Undecided Homes For Families firmly believes in allowing you to make the choice between adoption and parenting. We believe that while you are here God will give you direction for your life and that of your unborn child. EducationName of the last school attended:*Did you graduate?* Yes No If not, last grade completed?Have you ever been in special education classes?* Yes No If so, please list:At Homes for Families you have the opportunity to obtain your high school diploma. Is that something you are interested in?* Yes No MedicalDo you have allergies?* Yes No If yes, please list them:List any and all medication that you take:MedicationDosageReasonFor how long? Note: While we do not have a physician on staff, we are blessed with doctors in the community who see our residents and work with us to help evaluate, adjust, and taper medications when appropriate.Are you on a special diet?* Yes No If yes, please explain:If yes, was this diet prescribed by a doctor? Yes No Doctor's Name First Last PhoneDo you eat meat?* Yes No Do you have, or have you ever had, a problem with food or eating?* Yes No If yes, please explain:Have you been diagnosed with an eating disorder, or treated by a physican?* Yes No Doctor's Name First Last PhoneList any physical limitations and/or medical conditions (asthma, migraines, thyroid, diabetes, blood pressure, weight issues, heart problems, etc.) that you may have as indicated by a physician:*List all past surgeries or medical hospitalizations (include dates):* FinancialAre you on any type of government or financial assistance?* Yes No Will your coming to Homes For Families have any effect on this assistance?* Yes No Do you have any outstanding debts?* Yes No If yes, please explain:What arrangements will you make for their payment while you are in the program?Who will assist you with finances for your personal needs while at Homes For Families? (Church, ministry, family, or individual)*Note: Homes for Families provides food and shelter, but we are not responsible for medical expenses or prescriptions for you or your child(ren). It is each individual’s responsibility or their sponsoring agency to cover these expenses for themselves and for their child(ren). Arrangements should be made prior to residency in our program. If none of the above is available to you please inform the intake staff during your interview.Legal BackgroundHave you ever been arrested?* Yes No How many times?Please list date(s), charge(s), etc.DateChargeEtc. Do you have any pending court dates?* Yes No If yes, please explain:Are you currently incarcerated?* Yes No How long?Length of time remaining?Name of Attorney or Legal Representative:PhoneHave you ever been on probation or parole?* Yes, probation Yes, parole No, not either one Are you now?* Yes No How long?Length of time remaining?How often do you report?In person or through the mail?Name of probation or parole officer: First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Substance AbuseHave you ever experimented with the following substances? Check all that apply.* Alcohol Hallucinogenic (Acid, LSD, etc.) Morphine Amphetamines ("uppers") Crank Opium Barbiturates ("downers") Crystal Meth Heroin Cocaine Marijuana Ecstasy Crack Methamphetamines Tobacco Inhalants (Glue, Paint Thinner, etc.) Drug of Choice*Length of UseDrug of ChoiceLength of UseHabit cost per day?Longest period that you have been clean?Counseling and TreatmentHave you ever been diagnosed or treated for any of the following? Check all that apply. ADD/ADHD Bi-Polar Disorder Borderline Personality Disorder Dissociative Identity Disorder OCD PTSD Schizophrenia Have you ever had problems dissociating (losing track of time; finding yourself in a place and you don’t remember how you got there; having a sense of being outside of your own body)?* Yes No If yes, please briefly explain:Have you ever received counseling?* Yes No Please list facilities and counselors below:Have you ever received psychiatric care or been in a psychiatric hospital, rehabilitation, or substance detoxification program?* Yes No Please list facilities below:Date of EntryDate of DischargeProgram NameCity/StateReason for Leaving Have you ever been a victim of rape?* Yes No How old were you?Have you ever been a victim of incest?* Yes No How old were you?Have you ever been the victim of sexual abuse (including molestation)?* Yes No Have you ever been the victim of physical abuse?* Yes No Have you ever been the victim of ritual abuse?* Yes No Have you ever been involved in prostitution?* Yes No Have you ever experienced confusion about your sexuality?* Yes No If yes, please explain:Have you ever tried to commit suicide?* Yes No When?How?Why?Have you ever self-harmed?* Yes No How?If yes, for how long?Ever required medical treatment for self-harm? SpiritualHave you ever witnessed or been involved in occult activities?* Yes No Write a detailed explanation of your involvement with occult activities:Have you ever been abused in any of these activities?* Yes No Please explain:Have you had previous experience with any of these belief practices? Check all that apply. Brotherhood Jehovah’s Witnesses Scientology Christian Science Spiritualist Church Eastern Religions Mormonism Witches and Coven Freemasonry New Age Movement Secret Organizations Please describe:Have you ever received Jesus as your Lord and Savior?* Yes No DatePlaceIn what Denomination/Church Affiliate were you raised?*How active were your parents in their faith and beliefs?*Are you a member of any church?* Yes No If yes, name of church and pastor:How often do you attend church?Do you read the Bible?* Yes No How often?Do you ever pray?* Yes No How often?Do you feel that you have a need for God?* Yes No Please explain:What is your present relationship with God?*Why would you like to come to Homes for Families?*What would you like to see happen in your life while in this program?* I agree to comply with the rules and procedures and cooperate with the staff of Homes for Families. I understand that if I have failed to answer these questions truthfully or knowingly withheld any information, it may strongly be considered grounds for refusal into the program or discharge from the program due to noncompliance. I give permission for representatives of Homes for Families to speak with my lawyer, probation officer, CPS case worker(s), and/or whomever they deem necessary to obtain proper information to process my application for consideration into the Homes for Families.Signature*Date* MM slash DD slash YYYY You have reached the end of the application. Please click "Submit" below and your form will be sent to Homes for Families.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
Thank you for your interest in applying to Homes for Families. Please read all of the information carefully, including this brief introduction.
• Homes for Families is affiliated with STCH Ministries, a faith-based, nonprofit organization.
• Homes for Families uses resources and counseling to help women explore issues such as faith, forgiveness, family patterns, overcoming abuse, freedom from oppression and general principles and life skills for life-long success.
• Homes for Families uses resources from many different Christian teachers and pastors including: Charles Stanley, David Jeremiah, Neil T. Anderson, Dr’s. Cloud and Townsend and more. Applicants to Homes for Families should have a desire for help in a Christian atmosphere and should be willing to apply the principles of a biblical counseling program.
• This application serves to help us determine if we can meet your specific need for help. If for any reason we cannot help, we may be able to refer you to another organization. Please note that we are not a medical facility.
• No applicant can be sent to Homes for Families against her will or enter the program without showing a sincere desire to change. Accepted applicants will be asked to sign a Four Month Commitment form prior to entry.
• Homes for Families does not charge residents to be a part of the program; however residents are asked to provide their own medical expenses, whether through insurance, sponsorship, governmental benefits or personal contribution.
Phone Interview
After you submit your application, a Homes for Families staff member will contact you to schedule a phone interview. Your interview will take approximately one hour. Please be sure that you are alone and free to speak at the time scheduled for the phone interview.
This information is confidential. The information in this application will not be held against you or used to judge you in any way. Homes For Families is dedicated to helping those who need emotional and spiritual healing and restoration.
If for any reason Homes For Families cannot meet your particular need, we may be able to refer you to someone who can. Please answer all questions honestly so we may know how best to help you. Please do not leave any blanks in your application, as this will delay processing.
Note: While we do not have a physician on staff, we are blessed with doctors in the community who see our residents and work with us to help evaluate, adjust, and taper medications when appropriate.
You have reached the end of the application. Please click "Submit" below and your form will be sent to Homes for Families.
