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?
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?
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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