Well of GRACE Ministries Day Program Application

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1. Please fill in as completely as possible.

Please fill in as completely as possible.   Name:
Address:
Address 2:
City/Town:
State:	-- select state --AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming
ZIP/Postal Code:
Email Address:
Phone Number:

2. More about you

More about you   Date of Birth
Age
Marital Status
Age of Children
Religious preference and church affiliation
Last 4 digits of SS#

3. Are you employed?

Are you employed?   No Yes

If yes, please list employer.

4. Attending school?

Attending school?   No Yes

If yes, please list school.

5. Emergency Contact:

Emergency Contact:   Name
Relationship
Phone

6. Medical Information

Medical Information   Allergic to certain drugs Allergic to certain foods Allergic to other None Known

List specifics

7. Please list any physical conditions/diagnoses that you have.

Please list any physical conditions/diagnoses that you have.

8. Please list mental health issues and diagnoses.

Please list mental health issues and diagnoses.

9. Current Concerns (please check all that apply.)

Current Concerns (please check all that apply.)   Anxiety, nervousness Relationship problems Alcohol or drug problems Poor self-esteem Financial concerns Sadness, tearfulness Anger out of control Physical abuse Hearing voices/seeing things Thoughts of suicide Legal concerns Family conflict Poor sleep Eating problems Sexual abuse

Other (please specify)

10. How long have you been experiencing the problem(s) and what have you done to address the problem(s)?

How long have you been experiencing the problem(s) and what have you done to address the problem(s)?

11. Personal goals - please list one or more goals that you would like to accomplish during this program.

Personal goals - please list one or more goals that you would like to accomplish during this program.