Residential Application

First Name

Middle Name or Initial

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Sex

Male

Female

Date of Birth

Social Security

Does applicant have living family members?

Father

Mother

Sibling(s)

Father's Information

Father's First Name

Father's Last Name

Same address as applicant?

Yes

No

Father's Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Father's Phone Number

Father's Email (Optional—recommended)

Mother's Information

Mother's First Name

Mother's Last Name

Same address as applicant?

Yes

No

Mother's Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Mother's Phone Number

Mother's Email (Optional—recommended)

Sibling Information

Siblings

Sibling Name	Sibling Address	Sibling Phone	Sibling Email (Optional—recommended)

Which residence are you applying to?

Louisville, TN - Riverwood

Versailles, MO - New Hope

Diagnosis Information

Diagnosis

Approximate Date of Onset

Does the applicant have a diagnosed intellectual or developmental disability?"

Yes

No

What is the level of the disability?

Mild

Moderate

Severe

Profound

Has the applicant ever been treated for emotional problems?

Yes

No

Please describe the problem and treatment of emotional problems.

Describe the applicant’s general health

Is the applicant on a special diet?

Yes

No

Please describe applicant's dietary restrictions and needs

Please list any medications taken by applicant

Name of Medication	Medication Dosage	Medication Frequency

Vocational

Does the applicant have vocational training?

Yes

No

What type of work has the applicant done?

Is the applicant currently employed?

Yes

No

Where does the applicant currently work, and what do they do?

Faith and Spiritual Life

Where does the applicant attend church?

Minister's name

Church address

Address Line 1

Address Line 2

City

State

Zip Code

Financial Information

How will payment for services be made? (Check all that apply)

SSI or SS Benefits

Trust Fund

Family

Friends

Other

Please describe other financial sources

What benefits does the applicant currently receive?

Social Security

SSI

Food Stamps

Other

Social Security Benefits Recieved

$

SSI Benefits Recieved

$

Food Stamps Recieved

$

Supporting Documents

Before this application can be considered, it is necessary for us to have a copy of a recent psychological evaluation (within the past three years).

Choose File

If you have additional reports from schools, workshops, etc. that the applicant has attended, please attach a copy. (Attach up to 5 documents)

Choose File(s)

Before accepting a resident into our residential program, we must have a current picture of the applicant.

Choose File

By checking this box you affirm that all of the information you provided on this form is true and accurate to the best of your knowledge and that your name below serves as your electronic signature on this form.

First Name

Middle Initial/Name

Last Name

Your Relationship to Applicant

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Residential Application

Father's Information

Mother's Information

Sibling Information

Diagnosis Information

Vocational

General Information

Faith and Spiritual Life

Financial Information

Supporting Documents

Because Jesus' table is accessible for everyone...