House of Destiny - Recovery Healing Restoration


House of Destiny

PO Box 215     Votaw, Texas 77376

 

 

Application

   Applicants are considered for acceptance into House of Destiny based upon information required on this application, along with the medical questionnaire. Applicants must be sincere and truthful in their desire to seek a life of “change.”   We are totally committed to God to present an opportunity that will help you turn your life around and discover your true purpose in life. By completing the following application, you will enable HOD ministry to make an investment in your future. Thank you for contacting us. We’re here to help. STOP!(Do not proceed any further with this application unless you are READY FOR CHANGE!! Our desire is to help women who are ready to make a commitment of one year. We are not a motel, not a room for rent, not a get-out-of-jail-or-prison ticket, not a B&B, or homeless shelter. We are for REAL!! Be REAL with yourself and House of Destiny. If you are genuinely ready for CHANGE then complete this application truthfully.)

 

Please answer each section (Check all boxes)

 

Date _____________________

Name of Applicant ___________________________________________ Social Security #___________

Date of Birth ________________ Age ______________ Birth State ____________

DL # ____________________

Present Location: _______________________________________________________________________

Referred By: ___________________________________________________________________________

How did you hear about The House of Destiny? _____________________________________

Immediate Contact Name: __________________________________________
Phone Number: __________

Relationship: _______________________________________

 

Personal History:

 

Housing Status

 (Check one)

[ ] Own your home     [ ] Motel     [ ] Rent     [ ] Other     [ ] Live with others (friends, relatives, etc.)

Do you have a religious affiliation? Yes / No

Are you a member of a Church? Yes / No

Church Name and Address: ___________________________________________________________

 

Marital Status: (Circle One)

Married / Divorced / Separated / Widow / Single                     How Long? ___________

Marriage (s):

Name ____________________________Date of Marriage___________________

Spouse’s Location _______________________________________________________________________

 

Present Relationship:

Name __________________________________How Long _____________________________

Nature of Relationship ___________________________________________________________________

 

Number of Children: ______ 

 

Child/Children Ages: _______________________________________________

 

Hobbies:  _____________________________________________________________________

 

Education:

Highest grade completed ______ Name of School _____________________________________ City/State________________

GED Yes / No Vocational Training/Certificates: (Please List) _______________________

 

Legal Issues:

Are you currently on Probation/Parole?  Yes / No

Name of Probation/Parole Officer_________________________ County ____________________________

Do you have fees such as restitution, etc? Yes / No

If Yes, please explain:_____________________________________________________________________

Is there a warrant for you at this time?  Yes ___ No ___

 

List Felony Convictions:

 

Date/Charge/ Sentence/ Time Served:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

History of Violence:

 

Have you ever been involved in domestic violence? Yes / No

As a child, did you experience or witness domestic violence? Yes / No

 

Sexual History:

 

History of Sexual Violence

Incest   Yes ___ No___                       Assault   Yes ___ No___         Rape   Yes ___ No___

 

Are you ready to make a commitment for the next year (twelve months) toward a life of change?

______Yes    ______No    ALL areas of this application should be answered.

 

 

Please list reasons why you would like to be considered for internship at House of Destiny.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________ 

 

 

Consent Form:

 
 

I, ______________________________________, have read House of Destiny Guidelines. I agree to allow information gathered herein to be used as deemed necessary and appropriate by House of Destiny, its affiliates, and employees, for their ongoing ministry, whether I am accepted or not. The information provided herein shall become property of House of Destiny. While efforts will be made to keep information confidential, there is no guarantee this will be achieved and you agree to hold harmless, House of Destiny, volunteers, teachers, employees or affiliates.

 

I am aware that I will be in an ongoing evaluation of my progress while at House of Destiny. If at any time the evaluation of the staff believes that I am not taking the program seriously, not trying to make changes, or causing too many problems, then I will be dismissed. (Initial) _____

 

I am aware there is a $500 non-refundable deposit for the first month, and $500 per month for the duration of the year long program.  

 

I have arranged for monthly payments to continue through the twelve months.  

(Initial) ____

I have sponsorship for funding of my internship

(Initial) ____

I have family/friends/church who are willing to help with funding on a monthly basis.

(Initial) ____

 

 

Signed ______________________________________ Date _____________________

 

Received by __________________________________ Date _____________________

House of Destiny


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