Application | myfathershouse

Contact info:

Email: MyFathersHouseHiram@gmail.com
Phone: 678-435-5951

To be in the program, applications are accepted and reviewed by My Father's House. Acceptance is granted based on meeting the program criteria. If you or anyone you know might need assistance please contact Marsha Bowen.

Part 1:
Application for Admittance

The information in this application is considered confidential. This application is for screening purposes only and is not a commitment on either side that the applicant will become a client. If the applicant does become a client, any information falsified will be reason for immediate dismissal from the program.

First name

Last name

Date of Birth

Phone Number

Cell Phone Number

Current Residence

Street Address

City

State

Zip code

Are you at a facility? *

Yes

If yes, list contact person and phone number:

Relationship Status

If separated, divorced, or widowed, for how long?

If widowed, what was the cause of death?

Do you have children? *

Yes

How many?

List names and ages:

Where are your children now?

Do you have custody?

Yes

Do you have visitation rights?

Yes

Is DFACS involved?

Yes

Are you court ordered to pay child support?

Yes

Do you currently have legal problems? *

Yes

If yes, explain:

Do you have an attorney? *

Yes

If so, list attorney name:

Are you on parole/probation? *

Yes

For how long?

County/State:

Name of Officer:

How many times have you been incarcerated?

Education

Explain crimes that led to incarcerations:

Do you have a high school diploma? *

Yes

What grade did you complete?

GED? *

Yes

Have you ever been employed? *

Yes

If so, what was your last job and reason for leaving?

Do you have any physical or mental issues that would keep you from seeking employment? *

Yes

If yes, please list and indicate if you are receiving treatment, and where:

Lis any medication(s) you are currently taking:

Do you have any communicable diseases? *

Yes

If yes, please list and indicate if you are receiving treatment, and where:

Have you been tested for:

RPR

HIV

Hepatitis

Have you tested positive for any of these? *

Yes

Do you receive any Federal Assistance? *

Yes

If yes, explain:

Are you ready to commit to a one year Recovery Program? *

Yes

I am aware that any false information entered on this application will result in the immediate discharge from the program.

Now complete the Application Questionnaire below.

Part 2:
Application Questionnaire

First name

Last name

Do you smoke cigarettes? *

Yes

If yes, how much and for how long?

What age did you begin using drugs or alcohol?

Are you addicted? *

Yes

What is the longest time you have been clean since you started using?

Have you ever used a needle? *

Yes

List any narcotics you have taken, including any prescribed by a doctor:

When was the last time you used?

What did you use?

Do any of your family members struggle with addictions? *

Yes

If yes, who and what is the addiction?

Were you ever sexually molested as a child? *

Yes

Did you receive any counseling?

Yes

If you did received counseling, where?

Have you ever been physically abused? *

Yes

By whom?

Have you ever hurt or cut yourself? *

Yes

Have you ever had an eating disorder? *

Yes

Type of disorder?

Explain other:

Have you ever attempted to take your own life? *

Yes

Have you ever attempted to take someone else’s life? *

Yes

Do you now or have you ever heard voices? *

Yes

Have you ever been on mental health medications? *

Yes

When?

What medications?

Have you ever been involved in the sex industry? *

Yes

Have you ever been involved in the occult, witchcraft or satan worship? *

Yes

If yes, when and how long?

Do you believe in God? *

Yes

Do you believe the Bible is God’s Word? *

Yes

Have you ever accepted Jesus Christ as your personal Savior? *

Yes

If yes, when?

At any time in your life have you been involved in church? *

Yes

If yes, what denomination?

Are you interested in studying God’s Word and growing in your knowledge of Him?

Why have you chosen a Christian program?

What are your goals for the next 12 months?

What do you hope to be doing 5 years from now?

Thank you - we will get back with you shortly.

Download PDF Application

Contact info:

Email: MyFathersHouseHiram@gmail.com
Phone: 678-435-5951

Part 1:
Application for Admittance

Part 2:
Application Questionnaire

THOR Certified

Founded in 2011

Tobacco Free Facility

Contact info: Email: MyFathersHouseHiram@gmail.com Phone: 678-435-5951

Part 1: Application for Admittance

Part 2: Application Questionnaire

Contact info:

Email: MyFathersHouseHiram@gmail.com
Phone: 678-435-5951

Part 1:
Application for Admittance

Part 2:
Application Questionnaire