Date *

MM

DD

YYYY

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Mobile Phone *

(###)

###

####

Are You a US Citizen? *

Yes

No

Have Applied for Citizenship

Valid Forms of ID *

Check All That Apply

Driver’s License

Social Security Card

Birth Certificate

State ID

I Do Not Currently Have Any ID

Education *

Check All That Apply

Less than 12th Grade

High School Graduate

Earned My GED

Technical School

Some College

Associate’s Degree

Bachelor’s Degree

Other

Marital Status *

Single

Engaged

Maried

Separated

Divorced

Widowed

Do You Have Children? *

Yes

No

If Yes, Do They Live With You?

Yes

Now

Have You Ever Been Arrested? *

Yes

No

Have You Ever Been Incarcerated? *

Yes

No

Do You Have a History of Violent Sexual Offenses? *

Yes

No

Are You On Probation or Parole? *

Yes

No

Are You Permitted to Reside in Another County?

A county other than the one you were arrested in.

Yes

No

Unsure

Are You Aware of Outstanding Warrants? *

Yes

No

Which Best Describes Your Beliefs? *

I don't believe in God

I would describe myself as agnostic.

I believe there is a God, but I don't believe that He cares for me.

I believe there is a God, but I am angry with Him.

I want to learn more about God, but I have many questions.

I believe in Jesus and would describe myself as a Christian.

I practice a different belief system (Judaism, Buddhism, etc.),

Date

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

(###)

###

####

Date *

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

(###)

###

####

Do You Have Health Insurance *

Yes

No

Are You Pregnant? *

Yes

No

Unsure

Have You Been Tested for Communicable Disease? *

HIV, TB, Hepatitis C, STD or other.

Yes

No

Have You Ever Had a Seizure? *

Yes

No

Do You Have a Psychiatric Diagnosis? *

Depression, Anxiety, Biploar Disorder, Eating Disorder, Personality Disorder, etc.

Yes

No

Check All Health Conditions That Apply *

Cancer

Diabetes

Heart Disease

High Blood Pressure

Hepatitis

Glaucoma

Dental Disease

Seizure Disorder

Migraines / Cluster Headaches

Liver Disease

Gallbladder Disease

Ulcers

Kidney Disease

Thyroid Disorder

Asthma

Pulmonary Disease (including COPD)

Trauma

Other

NONE OF THE ABOVE

Do You Have Any Other Current Health Concerns? *

Yes

No

Check All Substances You Have Used

Alcohol

Opiates or Fentanyl

Cocaine, Including Crack Cocaine

Marijuana, Including Medical Cannabis

Hallucinogens (LSD, Mushrooms, Ecstasy, PCP, Angel Dust, etc.)

Amphetamines or Methamphetamines

Prescription Pain Meds (Hydrocodone, Oxycodone,

Synthetics (K2, etc.)

We do NOT permit cannabis on the premises. *

Click YES to agree NOT to bring cannabis of any kind on the premises.

Yes

No

Do You Smoke Cigarettes? *

Yes

No

Do you use any form of smokeless tobacco? *

Yes

No

Do you Vape, Juul, or use e-cigarettes? *

Yes

No

Do you want to live substance-free? *

Yes

No

Do you give Lydia’s Home permission to transport you to the nearest medical facility if you have a serious illness or injury? *

(Permission for emergency transport.)

Yes

No

Name *

First Name

Last Name

Date *

MM

DD

YYYY

Date *

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

(###)

###

####

Date *

MM

DD

YYYY

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Are You Currently Employed? *

Either Part Time or Full Time

Yes

No

Date *

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

(###)

###

####