Get Help

Contact Info.

Name *

Address *

Country

City

State

Zip code

Home Phone *

Work Phone

Email *

Background

Age *

Birth Date *

Social Security Number *

Are you receiving Medicaid? *

Yes

No

Are you receiving food stamps? *

Yes

No

If yes, what is the monthly amount? *

Are you receiving WIC? *

Yes

No

Are you receiving disability or social security? *

Yes

No

If yes, what is the monthly amount? *

Are you receiving any other assistance? *

Yes

No

If yes, what type of assistance? *

Pregnancy

Are you pregnant now? *

Yes

No

Thank you for the information you provided. Please read the instructions below.

You’ve indicated that you are not currently pregnant. You are not eligible to complete our resident application. Please contact Gina Tomes at 402.502.9224 with any questions you may have.

What is your due date?

What is the name of your baby's father? *

If unknown, enter "Unknown" for both first and last name.

What is your relation to the father of your baby?

Married

Divorced

In a relationship

Is he supportive of you living at Bethlehem House?

Yes

No

Have you been pregnant before? *

Yes

No

If yes, please list the names of your other children and their caregivers.

How many of your pregnancies ended in miscarriage? *

None

How many of your pregnancies ended in abortion? *

None

Family History

Mother's Name

Father's Name

Other Parent's Name

Are your biological parents married? *

Yes

No

Do your parents live with you? *

Yes

No

Do you have siblings? *

Yes

No

Please list your siblings' name, age, and address.

Education

Do you have a Diploma or GED? *

Yes

No

Where did you attend high school?

Are you currently attending school? *

Yes

No

If yes, what school are you enrolled at? *

Work Experience

Please list your last three places of employment.

Most Recent

Employer

Start - End Date

Responsibilities

Reason for Leaving

#2

Employer

Start - End Date

Responsibilities

Reason for Leaving

#3

Employer

Text

Responsibilities

Reason for Leaving

Faith

Do you believe in God? *

Yes

No

Do you attend church services? *

Yes

No

If yes, where? *

Relationship Status

If married or in a relationship, how long have you been together? *

Describe the person you're in a relationship with.

Personal History

Mark the types of abuse you have experienced: *

Emotional - When someone made you feel bad through harsh words or verbal intimidation.

Physical - When someone has caused you bodily harm.

Sexual - When someone has forced you to have intercourse, or touched you in ways you did not want to be.

None

Do you have a restraining order against anyone now or previously? *

Yes

No

Do you need help getting a protection order? *

Yes

No

Legal History

How many times have you been charged with:

Shoplifting *

Forgery *

Failure to Appear *

Vandalism *

Child Neglect *

DUI/DWI *

Theft *

Child Abuse *

Traffic Violations *

Are you on probation, parole or court supervision? *

Yes

No

Do you have any open court cases against you? *

Yes

No

Is there a warrant out for your arrest? *

Yes

No

Have you been arrested in the past? *

Yes

No

Have you ever been in jail or a juvenile detention program? *

Yes

No

Do you have any open Child Protective Services (CPS) cases open? *

Yes

No

Housing

Number of times you moved in your life? *

Have you ever been in foster care? *

Yes

No

How many foster homes have you lived in? *

Identification

Do you have a driver's license? *

Yes

No

Do you have a State I.D.? *

Yes

No

Do you have a copy of your birth certificate? *

Yes

No

Do you have a Social Security card? *

Yes

No

Do you have another form of valid I.D.? *

Yes

No

Substance Abuse

Do you smoke cigarettes or marijuana? *

Yes

No

Have you ever smoked cigarettes or marijuana? *

Yes

No

How many times in the last three months have your used:

Alcohol *

Cocaine *

Marijuana *

Amphetamines *

Narcotics *

Pills *

At what age was your first drug and/or alcohol use? *

Describe your drug and/or alcohol use (recreational, when alone, at parties, etc.) *

Have you ever been to, or received, drug and/or alcohol treatment? *

Yes

No

Do you feel you have a problem with drugs or alcohol use? *

Yes

No

If yes, please explain. *

Mental Health

Are you on any mental health drug prescriptions? *

Yes

No

If yes, please list the medication, doctor or clinic that prescribed it, and date prescribed. *

Have you ever attended counseling or therapy? *

Yes

No

Are you currently seeing a counselor or psychiatrist? *

Yes

No

If yes, please list the counselor or psychiatrist's name. *

Essay Questions

Please answer the following questions as thoroughly as possible. Some questions may have been asked elsewhere, but take this opportunity to share additional details.

Have you ever been involved in gang activity? *

Have you ever been physically, emotionally, or sexually abused? How old were you? How do you believe the abuse has affected your life? *

Describe your childhood. Do you feel it was safe/unsafe, healthy/unhealthy, lonely, happy, etc.? *

What do you do when you feel anxious or upset? *

How have you coped with crisis in the past? *

Who do you count on for emotional support? *

How long have you been sexually active? *

Have you ever attempted suicide? How old were you? Explain what happend. *

How do you typically respond to authority and authority figures (i.e. teachers, police, officers, a boss)? *

How do you deal with anger, and act when you're angry? *

List your hobbies and interests. *

Tell us why you wish to live at Bethlehem House. *

What are your goals? Where do you see yourself in two years? In five years? *

References

List the name, relationship and phone number of one to three of your references.

Agreement

Please read and agree to the following statement, and download the Expectations of Residency document using the link below.

Expectations of Residency

I hereby certify that the statements and information in this application form are true and correct to the best of my knowledge and belief, and I authorize Bethlehem House to investigate all statements or other information contained in this application for *

Yes

How to Apply

Resident Application

Contact Info.

Background

Pregnancy

Family History

Education

Work Experience

Faith

Relationship Status

Personal History

Legal History

Housing

Identification

Substance Abuse

Mental Health

Essay Questions

References

Agreement

Expectations of Residency

Bethlehem House

The Humble Lily