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Grace House of Cedar Creek Lake Application Please print plainly and fill in completely, Thank you!Who referred you? ____________________ Date of Application________________________________*Name____________________________________________ ID or SID#_________________POD____________*Address_______________________________________________________*Phone #_______________________*D.O.B.______________________________________ Age__________ Height__________ Weight__________*Race: Hispanic _____________Afro American _____________Anglo ____________Other____________*Languages: English__________ Spanish __________ Other: _____________________________________*Names of closest family members: What’s your hometown? ___________________________Names: ______________________________ How Related? ______________ Phone #_____________________Names: ______________________________ How Related? ______________ Phone #_____________________Names: ______________________________ How Related? ______________ Phone #_____________________Names: ______________________________ How Related? ______________ Phone #_____________________Names: ______________________________ How Related? ______________ Phone #_____________________*Education: Before high school: grade_____ High school: grade_____ Graduate______ GED______ Trade school _____ College_______ Graduate: yes____ no _____Type of Degree_________________________*Marital status: Married______ Single_____ Divorced______ Boyfriend? Yes______ No______*Sexual Orientation (Check One) Heterosexual_________ Homosexual________ Bisexual________*When did you last use: Alcohol____________ Tobacco _____________ Drugs _____________ Type of drugs_______________________________________________________________________________________*List all medications______________________________________________________________________*List any health or mental problems_______________________________________________________*Pending Court Case________________ Case#____________ County_________________ Court Date__________________ Judges name________________________ Court#__________ Expected release date___________________________________ *Lawyer name________________________________ phone_________________________ *Probation or Parole officer name____________________________ Phone___________________________List any & all previous criminal history: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________*How many children do you have? __________ Do you have custody? _________ Custodian name_____________________________________ Phone #_________________________________ CPS Caseworker name______________________________________ phone________________________*Reason for residing at Grace House? (Check any that apply) Spiritual growth________ Job training________ Life skills ________ Finances________ Shelter________ Overcome drug/alcohol abuse________ List your talents and abilities_______________________________________________________________________________**Why do you want to reside at Grace House? (Please print/ use 2nd page if needed)** ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Release of InformationI, _______________________________________________, hereby authorize Grace House to obtain any information pertaining to any charges, convictions, medical data and personal information. I also give Grace House permission to use any on this form.Applicant Printed Name_______________________________________________________________________Other names used _________________________________________________________________________ Applicant Signature________________________________________________________________Date______________________You will be notified when a decision is made & will have letter to provide to lawyer, judge, parole, etc.Applications can be returned by mail to:or email: Grace House of Cedar Creek LakeKristyf.gracehouse@ P.O. Box 43012 Crystalgayle.gracehouse@ Seven Points, Texas 75143 Meghano.gracehouse@**************************************************************************************************Office use only Scanned & emailed ________________________ Assessment needed _____________________ Denied_________________________ Referred out to________________________________________________________________ Approved____________________________________ Eligibility Dates _______________________________________________ Contacted______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ................
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