Women in Transition TULSA Neighbor Application

Please note that no question can be left blank. You can put NA in the answers that do not apply to you.

If you are applying to be a VOLUNTEER, please do not fill out this application. Contact your Program Manager for a Volunteer Application.

First Name *

Middle Name *

Maiden Name *

Last Name *

Age *

Birth Date *

// (mm/dd/yyyy)

Referral Source/Housing *

DHS
Hope Pregnancy Center
Phoenix Rising
Tulsa Boys Home
Tulsa Hills Youth Ranch
Walker Hall
Youth Villages
Branch 15
Christian Helping Hands
Dunamis House
Grace House
His House
Hope House
Jehovah Jireh
OBCH
Private Housing
Other

Other Housing:

Address *

City *

State *

Zip *

Email *

Cell Phone *

Other Phone *

Phone Type *

Race *

African American
Asian
Caucasian
Hispanic
Native American
Other
Blended

SPIRITUALITY

Do you currently attend church or any type of group Bible study? *

Yes
No

Church (list campus if applicable) *

Please provide location. *

How long have you been participating? *

Do you have a religious/denominational preference? If so, what? *

FAMILY INFORMATION

Do you have children? *

Yes
No

Number of Children *

What are their Ages? *

Have your parental rights been terminated? *

Yes
No
Doesn't apply to me

If not, will you be seeking (check all that apply): *

Reunification (Children Living With You)
Reunification (Have a Relationship with your children)
Visitation
Joint Custody
Termination of parental rights
Doesn't apply to me

Currently, children are in the care of: *

Family member, guardianship
Family member, kinship foster care
Foster care, non-family
DHS shelter or residential placement
Doesn't apply to me

If so, what City and State? *

Marital Status *

Single
Legally Separated
Married
Divorced
Widowed

If married, how does your husband feel about your involvement and time committment to this program? *

Is/was your husband a participant or enabler in your previous criminal activities? *

Yes
No
Not married

If yes, explain. *

EMERGENCY CONTACT

Name *

Relationship *

Contact's Address *

City, State and Zip *

Contact's Cell Phone *

INCARCERATION

From what facility were you released? *

How much time did you serve? *

When were you released? *

What was the nature of your charge? *

Violent Crime
Robbery
Drug Related
Other

If you checked violent crime or other, please explain. *

Are you on Probation? Parole? *

Probation
Parole
Neither

If so, list Probation/Parole Officer's Name and contact information. *

PERSONAL

RECOVERY: Are you participating in/attending a recovery group? *

Yes
No

Name/Location of Program *

How often do you meet? *

Name of the group facilitator *

RELATIONSHIPS - Are you currently dating or in an intimate relationship? *

Yes
No

If yes, please explain. *

HEALTH - Do you currently take prescription medication? *

Yes
No

If yes, list all medications and reason prescribed. *

Please list any mental health diagnosis received. *

Prescribing Physician: *

EMPLOYMENT

Are you currently employed? *

Yes
No

Company Name and location: *

Position *

If not employed, how are you supporting yourself? *

Are you looking for work? *

Yes
No

If not, please explain. *

EDUCATION

Are you currently attending school? *

Yes
No

Certificates received *

High School
GED
Associates Degree
Bachelors Degree
Other

RESOURCES OR SUPPORTS REQUIRED

What are your needs or goals for the following Reources and Supports?

Housing *

Employment *

Education *

Transportation *

Family Reunification *

Other Supports (Money management, banking, legal aide, etc._) *

Neon CRM by Neon One

Women in Transition TULSA Neighbor Application

Tulsa

Oklahoma City

Get Monthly News and updates Sent Right to Your Inbox.

Make a Financial Contribution to Stand in the Gap Ministries

Timeout Warning

Women in Transition TULSA Neighbor Application

Tulsa

Oklahoma City

Get Monthly News and updates Sent Right to Your Inbox.

Make a Financial Contribution to Stand in the Gap Ministries