Resident Application

Contact Details

First Name

Last Name

Cell Phone

Home Phone

Personal Email

Mailing Street

Mailing City

Mailing State

Mailing Zip/Postal Code

Date of Birth

DD/MM/YYYY

Gender

US Citizen

Military Service?

Marital Status

Number of Children

Current Living Situation

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Email

Emergency Contact Phone

Emergency Contact Address

Relationship to Emergency Contact

Application Details

Who referred you to His Mansion?

Have you applied before?

How many prior applications and when?

Physical, Emotional, Mental and Behavioral Background

The following information is necessary for us to understand the care you need. Please answer honestly. Unwillingness to disclose the following information may disqualify you from entering the program.

Height

Weight

Do you have any medical conditions or health issues?

Describe health issues:

Are you diagnosed with a learning disability?

Describe learning disability:

Have you been diagnosed by a mental health professional?

Describe mental health diagnosis:

Currently Taking Medical Prescriptions?

List all prescription medications:

Have you ever been hospitalized for emotional or behavioral problems?

Describe hospitalizations:

Did hospitalizations occur in last 6 months?

Do you have any allergies?

Describe allergies:

Is your diet restricted in any way?

Describe dietary restrictions:

Are you aware that His Mansion Residential Program has a strong work component?

Do you have any health problems that hinder you from doing physical work, including heavy lifting?

Describe physical restrictions:

Legal Background

We do not offer our program as a pre-release arrangement/alternative for parole, and individuals cannot be mandated into our program. However, we are able to work with individuals on parole or probation.

Do you have a criminal record?

Describe your criminal record:

Are you court ordered to participate in a drug treatment program?

Describe court order:

Do you have any pending legal issues with the criminal justice system?

Describe pending legal items:

Are you on probation or parole?

Describe probation or parole:

Are you legally required to register as a sex offender with your state, local police department?

Spiritual Background

Please note: you do not have to be a Christian to attend the His Mansion Residential Program. However, we ask that you briefly describe your spiritual background if applicable.

Do you attend a church?

Church name:

Description of your experience with this church:

Short Essay

Carefully read the following questions and answer them honestly and thoughtfully. Answers must be completed thoroughly. Applications with incomplete answers will not be considered for review.

Who is God to you and does he play a role in your life?

Why does the His Mansion Residential Program seem like a good fit for you?

Describe the areas you are currently struggling with and for how long:

Primary Address Type

Mailing Country

Application Type

Contact Information

Substance Use/Abuse	Mental Health Challenges
Suicide Attempt/Ideation	Sexual Addiction/Pornography
Gender/Sexual Identity	Eating Disorder
Trauma/Crisis	Other