Abba House Application

Please read before continuing:

We are designed to make Disciples of Christ, and our recovery is centered on the principles and disciplines found in the Bible. We need our Students to be willing to surrender and give 100%. If you cannot handle being without a relationship or have a problem with someone getting in your business, you need to stop filling out this application. Remember your way does not work, so you must be willing to allow us to help you develop a new way of living. We have never had anyone surrender to the structure of the program and fail! Those who fail are those who refuse to surrender and try to hold onto the old way of living.

First Name

Last Name

Birthdate

City/State/County of birth

Social Security

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Email

ID/License Number

Expiration Date

State Issued

Marital Status

Spouse's Name

Emergency Contact

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Name & age of children

Explain your relationship with your children & their mother/guardian.

Immediate family members

Are you a sex offender?

Yes

No

Do you currently have any pending charges or indictments related to sexual offenses or crimes of a sexual nature?

Yes

No

If other, explain...

Explain your reason for applying to come into Abba House and what you are hoping to achieve?

References

family, friend, pastor, therapist, probation/parole, etc.

Reference 1

First Name

Last Name

Relationship

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Reference 2

First Name

Last Name

Relationship

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Reference 3

First Name

Last Name

Relationship

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Education, Employment, & Income

Check all that apply

High School Diploma

G.E.D.

College Degree

Have you ever served in the United States Armed Forces (Active Duty, National Guard, or Reserves)?

Yes

No

If yes, please list branch, dates of service, & discharge status (if applicable):

Are you currently employed?

Yes

No

Company

Supevisor Name

Phone Number

Work experience:

List any special skills or job training you have:

Total monthly income:

Total monthly expenses:

Legal Records

List all arrests you have had, DUI/DWI, Misdemeanors, Felonies, Restraining Order, Arrests, Incarcerations, etc. (Date Arrested/Charges/Results)

Do you have pending charges/upcoming cases?

Yes

No

If yes, when?

What are the charges?

Are you currently on probation or parole?

Yes

No

If yes, when does your probation/parole end?

Name of Probation/Parole Officer

Probation/Parole Phone Number

Name of Attorney

Attorney Phone Number

Have you ever been involved in a domestic violence situation?

Yes

No

Is an order of protection against you in the State of Missouri?

Yes

No

Have you ever been under a doctor's care for any reason in the last year?

Yes

No

If yes, for how long?

Do you take medication or need medical attention regularly?

Yes

No

If yes, list the medications/dosages and any medical needs you have:

Do you have a disability, artificial limb, wear a brace, service dog, or have a handicap of any kind?

Yes

No

If yes, please explain:

Have you ever had high blood pressure or any kind of heart disease?

Yes

No

If yes, what is your current treatment?

Have you ever had any sexually transmitted diseases?

Yes

No

If yes, explain:

Date of your last physical checkup!

Primary Care Physician

Have you ever received treatment or counseling for emotional or psychological problems?

Yes

No

If yes, explain:

Have you ever been hospitalized Or taken to the emergency room because of drug abuse and/or alcoholism?

Yes

No

If yes, when? Explain:

If other, please explain:

Do you have a counselor or psychiatrist?

Yes

No

Current Counselor or Psychiatrist

Phone Number

City

Organization

How would you describe your current mental state?

Personal Habits & Addiction History

Have you ever used any mind-altering or mood-altering substances (including drugs or alcohol)?

Yes

No

If other, please specify: