Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
Gender
*
Date of Birth
*
Marital Status
*
Single
Dating
Married
Separated
Divorced
Widowed
Are you in an active relationship?
*
Yes
No
Spouse's Name
First Name
Last Name
Spouse's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Spouse's Phone Number
(###)
###
####
Spouse's Occupation
Do you have children?
*
Yes
No
Child Support?
*
Yes
No
Please list your children's names, ages, and dates of birth:
List all previous spouses (if applicable):
What is the highest grade you have completed?
List any specific areas of training you have had:
What are your future educational goals?
List your favorite pastimes/hobbies:
What is or was your most current employment status? (place, position)
How long have you been or were you employed there?
Can you return?
Yes
No
Not Sure
Are you physically, emotionally, and mentally able to handle full-time work?
Yes
No
Have you ever had any criminal charges?
*
Yes
No
List all local, out of the country, and out of state charges and the dates:
How many times have you been in prison?
What were the charges and the dates of each stay?
Do you have any upcoming court cases/legal issues pending?
*
Yes
No
Explain:
Probation/Parole:
Yes
No
How long?
Present (or past) Probation/Parole Officer's Name:
Phone Number
Do you come under Megan's Law as a sex offender?
*
Yes
No
Any sexually related charges or convictions?
*
Yes
No
Do you have any misconduct charges while in prison?
Yes
No
How many misconducts did you have?
What where the misconducts for?
What needs to change in your life, so you do not go back into prison? (Select all that apply)
If "other", please explain:
Have you accepted Jesus Christ as your personal Lord and Savior?
Yes
No
Are you committed to following him?
Yes
No
Most recent church attended:
Do you have a home church? Name:
Present Chaplain/Pastor's Name:
Phone Number
List any current medical conditions and any history of serious illness
Have you ever been diagnosed with Hepatitis?
Yes
No
If yes, check one:
Have you received medical care for this?
Yes
No
Has it been cured/resolved?
Yes
No
When?
Have you ever been diagnosed with any mental health conditions?
Yes
No
If Yes, what was the diagnosis?
Date you were diagnosed?
What mental health medications have you been prescribed in the past? Name, Dose & Purpose
What medications are you taking currently? (and intend to bring/take at Potter’s House) Name, Dose & Purpose
***NOTE: YOU MUST ENTER WITH 30 DAYS OF MEDICATION -- NO EXCEPTIONS***
Do you have medical insurance?
Yes
No
In case of emergency, who should be contacted?
First Name
Last Name
Phone
(###)
###
####
Are you now clean and sober?
*
Yes
No
How long?
*
Date of last use?
MM
DD
YYYY
Have you recently struggled with any of the following addictions? (Mark all that apply)
If other, please explain:
Are you currently receiving treatment of any kind for substance abuse?
Yes
No
Describe
List all recovery, rehab programs, or ministries that you have participated in. Include dates.
Are you involved with an AA/NA/CR group?
Yes
No
What/Where is your home group?
Father's Name
First Name
Last Name
Father's Phone
(###)
###
####
Mother's Name
First Name
Last Name
Mother's Phone
(###)
###
####
Describe any changes that should happen in your relationship with your parents
Describe briefly any history of addictions in your family.
Are there any other significant family relationships or issues we should be aware of?
Why do you want to live at The Potter’s House? (Mark all that apply)
If other, please explain:
What are the goals you want to accomplish while at The Potter’s House?
Explain how you will commit to and respect the Objectives of The Potter’s House PartnershipPlan? If you feel you cannot commit to the plan, explain why you cannot and why youfeel you should still be accepted
