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Office:
479-621-0385
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Mandated Reporters
Who We Are
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Staff and Board
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Internships
What We Do
Programs and Services
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Training Opportunities
Get Involved
Volunteer
Restorative Giving Society
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Christmas Program
Events
Cherishing Children Rally
Family Fun Festival
Restoring Lives: Evening of Impact
In It to End It
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Get Help
Residential Application
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Residential Application
Resources
If you are seeking safe shelter and resources
Residential Application
First Name
Last Name
Race
Select
Caucasian
African American
Native American
Latino/Hispanic
Other
Birthdate
Age
DL Number
If no DL Number, do you have a state ID?
Yes
No
Street Address
City
State
Zip
Phone
Email
Marital Status
Select
Married
Divorced
Separated
Widowed
Single
In Case of Emergency Contact
Describe your current living situation over the last four months
What has happened that has you considering a change in your living situation?
Do you have any children with you?
Do you have any children NOT with you?
Do you have visitation?
Yes
No
Reason children are not with you?
Do any of your children have any mental or developmental delays?
Yes
No
If yes, please explain:
Are any of your children receiving counseling or additional services?
Yes
No
If yes, please explain:
Insurance Provider
Insurance Number
Identified Disabilities:
Child Insurance Information
Primary Care Doctor
Primary Care Contact Number
Please list any medical conditions
List any allergies/dietary concern
Are You Pregnant?
Yes
No
If so, what is your due date?
Current Medications (List prescription and OTC)
Current Child Medications (List prescription and OTC)
Do you currently receive counseling?
Yes
No
If yes, how often?
Where do you receive counseling?
Counselor
Psychiatrist
Have you ever been treated for wanting to hurt yourself or others?
Yes
No
If yes, when?
Have you been diagnosed with a mental illness/condition?
Yes
No
If yes, what?
Are any of your children diagnosed with a mental illness/ condition?
Yes
No
If yes, what?
Please list your support system (ie family/friends/mentor/sponsor/church etc.)
Check highest grade completed:
GED
9
10
11
12
College Level
1
2
3
4
Other
Does your future include completing any of the following? (check all applicable)
GED
High School
Vocational Training
College Degree
Do you have a car?
Yes
No
Do you have car insurance?
Yes
No
Vehicle Information
Are you currently employeed?
Yes
No
If so, where?
Please list any other sources of income such as child support, unemployment, social security, or disability benefits, etc.:
Have you ever been arrested?
Yes
No
If so, what for?
Have you ever spent time in jail/prison?
Yes
No
If so, when?
Are you currently on probation or parole?
Yes
No
If so:
Do you currently have any outstanding warrants?
Yes
No
If so, where?
Do you have a No Contact or Order of Protection against anyone?
Yes
No
If so, who?
Does anyone have a No Contact or Order of Protection against you?
Yes
No
If so, who?
Is there an open DHS case?
Yes
No
If so, please give county and Case Worker name
Have you ever taken illegal drugs?
Yes
No
If so, what?
When was the last time?
Do you drink alcohol?
Yes
No
When was the last time?
Have you ever been in treatment for drugs or alcohol?
Yes
No
If yes, where?
If yes, when?
Did you complete the program?
Yes
No
How are you related to your current abuser?
Name of Abuser
Race
Age
Sex
Height
Weight
Eye Color
Hair Color
City/State Address of Abuser
Any markings?
Car make, model, color
Describe abuser’s alcohol/drug use:
Describe abuser’s criminal history:
Did your children witness the abuse or experience any abuse?
Types of abuse you have experienced:
Physical
Sexual
Emotional
Mental
Verbal
Have you ever stayed in any shelters?
Yes
No
If yes, when and where?
Submit
Safety Exit
Safety Exit
