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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#__________________________________ *Address______________________________________________________________________*Phone #_______________________*D.O.B.______________________________ Age__________ Height__________ Weight__________ Race: ________________*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 #_____________________*Highest level of education: __________________________________________________________________________________ *Marital status: _____________________________________________________________ Boyfriend? Yes______ No______*Sexual orientation: (check one) Heterosexual_______ Homosexual_______ Bisexual_______*How many children do you have? __________ Do you have custody? _________*When did you last use: Alcohol_________________ Tobacco __________________ Drugs _________________ Type of drugs_________________________________________________________________________________________________*List all medications______________________________________________________________________*List any health or mental problems_______________________________________________________*Pending Court Case__________________________________________________________________________________________County____________________________ Court Date__________________ Expected release date_______________________ *Lawyer name_________________________________________________________________ phone_________________________ *Probation/Parole officer name______________________________________________ Phone_________________________List any & all previous criminal history & record of incarceration: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________**Why do you want to reside at Grace House? Do you believe in Jesus? List any talents or special abilities. (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. (Other names ____________________________________________)Applicant Signature________________________________________________________________Date______________________Applicant email_______________________________________________________________________________________________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: Grace House of Cedar Creek LakeOr email: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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