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Gospel Homes for Women

30 Lawrence Avenue Colorado Springs, CO 80909

719-291-3406 cell 719-633-5079 home Dir. Rev. Marilyn Vyzourek

APPLICATION FOR WOMANS PROGRAM edited June 2016

Please be honest. We will strongly consider all applicants. Fill out the following completely, Incomplete

applications will be returned. Do not leave any questions blank. You may put “ not applicable” if needed.

Send a printout of all disciplinary actions if you are coming from prison. Have your Case Manager sign them to verify their validity.

NAME ______AGE____

LAST FIRST MIDDLE

DOC#______DOB______Religious Affiliation (if any)______

List all current convictions ______
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List all your material resources to include such things as savings account balance, automobiles, insurance coverage, etc.

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Plea Bargain/trial______Did you knows the victim? ______

Sentence Length ______Was it aggravated? ______

Please answer below as to which entity you are currently detained in.

COUNTY

Next Court Date ______PED______MRD______

Division______Case Manager______

Probation Officer ______Parole Officer______

Lawyer______Facility Incarcerated In______

PERSONAL INCARCERATION INFORMATION

How many times have you met the parole board? ______

How many years were you incarcerated as an adult? ______

How many years were you incarcerated as a juvenile? ______

How many times have you had institutional write-ups? ______

How much “good time” have you lost? ______

Describe the nature of the crime’s (or situations) for which you are currently incarcerated (or homeless)?

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What actions have you taken to improve yourself and prepare for life outside the prison (or streets)?

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How do you think you will deal with your parole or discharge (or new life)?

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List all prior convictions

Date Charge Sentence Time Served

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Age you were first arrested ______Drug (s) of choice______

Are you affiliated with a particular gang? ______

Are any family members associated with ______?

a particular gang? (This does not disqualify you from the program)

List facilities in which you have served time:

Facility Supportive Persons Mentor Dates

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Prison Jobs/Assignments

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List any hobbies______

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Family Status

Never been married ______Married ______Divorced______How many times married______

Spouses name ______Spouses phone number______

Spouses address______City, State Zip Code ______

Children:

Name Age Do you have contact with them and how?

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Is your father alive? Yes___ No______Is your mother alive? Yes____ No______

Name Name

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Address Address

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City State Zip City State Zip

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Phone Phone

Is it all right if we contact them on your behalf? ______

Describe Relationship with Mother Describe Relationship with Father

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Any Living Brothers or Sisters?

Name ______Address______Phone______

Name ______Address______Phone______

Name ______Address______Phone______

Name ______Address______Phone______

Is there a significant other male or female in your life? Yes______No______

Give name and relationship______

Children? ______

List any other mentors, pastors, good friends with whom you wish to have a continued relationship, along with their addresses and phone numbers:

Debts and Moneys Owed:

Past child support owed? ______Currently monthly payment? ______

Is there a court order for this? ______

Explain______

Court Ordered Restitution or Fines? ______How much? ______

Is your driver’s license clean? ______

List any fines, restrictions, required classes, needing to be complete

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List any other debts or financial obligations that you have amounts and schedules of payments

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Health:

Date of last physical or doctors appointment ______While incarcerated? ______

Diagnosis and treatment: ______

Mental/Emotional problems______

Treatment______

Have you been tested for HIV or AIDS? Results______

Have you been tested for Hepatitis? ______TB______

Any other health problems that we should be aware of? ______

Any special dietary needs? ______Any prescription medications?______

Any allergies to medications?______

EDUCATION:

Grade completed______Age ______Diploma or GED?______

List all classes taken while in prison and grades received: Completed?

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MILITARY SERVICE:

Branch______Date of Service ______

EMPLOYMENT HISTORY: Prior to incarceration

List all employers for 3 years prior to arrest:

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Employer Address Dates Reason for leaving

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Employer Address Dates Reason for leaving

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Employer Address Dates Reason for leaving

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Employer Address Dates Reason for leaving

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Employer Address Dates Reason for leaving

As you look back on your time in prison (or your last couple years), what good things can you see that will help you now?

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Have you ever been in another rehabilitation program? If so, where and when?

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Have you ever been had impatient psychiatric care? If so, where and when? Diagnosis?

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Which of the following contributed to your incarceration (or current circumstances)? Identify the degree of negative influence, 1 being the least influential and 5 being the most influential.

____alcohol _____myself ______friends, relatives, etc ______lack of education

_____ poor decisions _____ poor attitude _____ poverty/homelessness ______drugs/alcohol

___ pornography _____ anger ______association ______lack of motivation

_____ traumatic event in your life ______giving up

What are you doing to change the areas listed above? ______

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WHY WOULD YOU LIKE TO BE ACCEPTED TO THIS PROGRAM?

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Signature date