Offering A Transformational Housing Experience

Christian Family Homes - Screening Application

Pre-Screening Application
First Name and Last Name (Please enter the name provided on your legal identification.)
A contact number is required for a member of our staff to follow up with you on this application.
What is the applicant's date of birth?
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What is the applicant's gender?
When are you seeking recovery housing?
Substance Use Disorder Treatment
Have you ever been enrolled in treatment for a substance use disorder?
When was the last time that you abused a mind/mood altering substance?
Have you ever been diagnosed with a mental health disorder?
If you are not taking any prescribed medication, enter NONE.
Self-Harm History
Do you have a history of self-harm?
What is your current relationship status?
Children/Dependents
Do you currently have children in your care?
Pre-Trial, Charges and Sentencing
Are you currently awaiting charges, trial or sentencing for a crime?
Charges, Sentence, etc.
Who referred you to Dismas House of Kansas City for housing support?
Do you presently have any physical, mental or behavioral challenges that would limit your participation in treatment and/or sustaining employment?
If you answered yes, please provide us with an explanation of your limitations:

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