Harvest House Transitional Residence

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* Indicates required field

Name *

First

Last

Email Address *

Name of Agency Person who referred you *

First

Last

If not referred, how did you hear about the program? *

Contact Information *

Social Security Number *

Date of Birth *

Age *

Where did you stay last night? *

How long there? *

First time homeless? *

Number of times homeless *

Income Source *

Average Monthly Income *

Total Income Received Last Month *

Explain any expected income changes *

If employed, list employers name, address and phone# *

Physical Disability *

No Yes Don't Know

Developmental Disability *

No Yes

Health Status *

Excellent Good Fair Poor

Pregnant *

No Yes Don't Know

Children *

No Yes

Are children in YOUR custody? *

No Yes

Name and Ages of Children *

Nearest Relative's Name *

First

Last

[object Object]

Relation *

Phone *

Date of Last Physical *

Doctor's Name *

First

Last

[object Object]

Phone *

Please list all prescriptions you are currently taking (or should be taking) and any medications currently in your possession *

Please write a brief health history and description of your current physical and mental health issues and challenges *

Name of your Therapist(s) or Specialist *

First

Last

Phone *

Social Worker(s) *

Phone *

Are you now or have you been a substance abuser? *

No Yes

If yes, when? *

If yes, what? *

Are you now or have you been in recovery? *

No Yes

If so, how many times? *

When? *

Where? *

Current length of time in sobriety and/or drug free *

Have you ever been in an abusive relationship? *

No Yes

If so, please describe *

Please explain your criminal history *

What in your opinion has contributed to you being in your present state (homeless)? *

Please write a brief personal history *

What do you expect a transitional program to do for you and how will you use this program to your best advantage? *

Submit

Trenny McCollumn, Founder and Director

Telephone: 1-800-577-7358

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Home
Donate
Mission
Success Stories
Health and Wellness
Apply Online
Resources
Contact
- Contact Us
- Board of Directors
Our Videos
Facebook
Twitter

Support Us

Apply Online

Trenny McCollumn​, Founder and Director

Trenny McCollumn, Founder and Director