First Name

Last Name

Country

City

State

Cell Number

Email

Social Security No.

Date of Birth and Age

Drivers License/ID

State Issued

License Currently Valid
Yes
No

Emergency Contact

Cell No.

Do You Have An Income
Yes
No

Do You Receive Food Stamps
Yes
No

Marital Status
Single
Married
Separated
Divorced
Widowed

List Reasons for Separation or Divorce

Husband's First Name

Husband's Last Name

Country

City

State

Husband's DOB

Husband's Cell

Do You Have Children?
Yes
No

Do You Pay Child Support?
Yes
No

If Yes, How Much Do You Pay?

Are You Able To Read and Write?
Yes
No

Did You Earn A GED?
Yes
No

Did You Graduate High School?
Yes
No

Did You Attend College?
Yes
No

Are You Currently Employed?
Yes
No

Please Provide a Complete Work History For the Past 5 Years

Show Any Additional Skills/Talents You May Have, Like Sewing, Cooking, Gardening, Etc.

Are There Any Current Charges Pending Against You At This Time?
Yes
No

Do You Have An Active Warrant For Your Arrest?
No
Yes

Are You Currently On Parole Or Probation
No
Yes

Have You Spent Time In Jail or Prison?
No
Yes

Have You Ever Been Charged With Any Sexual Crime?
No
Yes

If Yes -- Please Explain?

What is the State of Your Health?

List All The Major Illnesses That You Have or Have Had

Date You Were Last Tested for HIV?

Date You Were Last Tested for Hepatitis C?

Date You Were Last Tested for Tuberculosis?

Do You Use Tobacco?
None
Smoke
Vape
Chew
Patches

If Yes, Exactly What Kind and For How Long?

Are You Taking Any Prescriptions or Over The Counter Medications?
No
Yes

Please List All Medications, Dosages, How Often, and How Long You've Been Taking Them

Please List Any Side Effects Associated With Your Medication

Have You Ever Suffered From Depression?
No
Yes

If Yes, Please Describe Your Condition And The Treatment You Received

Have You Ever Considered Suicide?

Please Give the Month And Year

Have You Ever Attempted Suicide?

Please Give the Reason Why

List Any Rehabilitation Centers You have Attended

What Was Your Drink / Drug / Food / of Choice?

What Age Was Your First Drinking / Drugging / Overeating Experience?

When Did You Last Drink / Drug / Binge On Food?

What Drink / Drug / Food Did You Binge On?

Do You Think You Will Need to Detox Before Entering The CWRH Ministry?
No
Yes
Not Sure

How Would You Describe Your Sexual Life Style?
Straight
Gay
Lesbian
Bisexual
Transgender

Have You Ever Participated In An Alternative Lifestyle?
No
Yes

Have You Ever Struggled With An Eating Disorder?
No
Yes

If Yes, Please Describe Your Specific Disorder

Have You Ever Physically Harmed Yourself (i.e., Cutting, Hanging)?
No
Yes

If Yes, Please Describe When And How

Do You Realize That Calvary Women's Restoration House is a Christ-Centered, Biblically-Based Ministry?
No
Yes

Do You Have A Relationship With God?
No
Yes

Please Describe Your Religious Beliefs

Do You Read The Bible?
No
Yes

Do You Pray?
No
Yes

If Pastor or Church, Pastor's First Name

Pastor's Last Name

Country

City

State

Pastor's Cell or Church's Office Number

Share The Reason Why You Are Seeking Help

Do You Understand That Calvary Women's Restoration House Is A One Year Commitment?
No
Yes

Please Share Your Thoughts About Making This Commitment And Your Willingness To Do So

You Must Read the Posted Handbook In Order to Enter The Ministry. Have You Read The Handbook?
No
Yes

First And Last Name (Considered To Be An E-Signature)

Date