Application

Gospel Homes for Women  marilynvyz@yahoo.com

30 Lawrence Avenue Colorado Springs, CO 80909

719-291-3406  cell  719-633-5079 home

Dir.  Rev. Marilyn Vyzourek

APPLICATION FOR WOMEN’S PROGRAM

                                                               to download click: programapplicationGHW

 

NAME ________________________________________________________________ AGE____
LAST                                            FIRST                                  MIDDLE

DOC#___________________ DOB______________ Religious Affiliation (if any)_______________

Phone________________________ Email_________________________

CURRENT SITUATION:

Are you currently incarcerated?______ Where?___________ Date placed in custody?___________

If not in custody- are you currently homeless?____ Describe your living situation_____________________

List all current convictions ( or charges?) _________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Describe the nature of the crime’s (or situations) for which you are currently incarcerated (or homeless)?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________________

Plea Bargain/trial__________________________ Did you know the victim? _____ Relationship?___
Sentence Length _____________________Was it aggravated? _________________

Please answer below as to which entity you are currently detained in.
COUNTY _________________

Next Court Date __________________ PED_________ MRD______________

Division_________________________ Case Manager_____________________

Probation Officer _________________ Parole Officer_____________________

Lawyer__________________________ Facility Incarcerated In______________

PERSONAL INCARCERATION INFORMATION

Age you were first arrested______ Age you were first convicted of a felony_______

How many times have you met the parole board? ____________________________

How many years were you incarcerated as an adult? _________ As a juvenile? _____________

How many times have you had institutional write-ups? _____How much “good time” have you lost? ____

What actions have you taken to improve yourself and prepare for life outside the prison (or streets)?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

How do you think you will deal with your parole or discharge (or new life)?
______________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
List all prior convictions
Date                        Charge                                 Sentence                             Time Served
___________ ________________ _________________ _____________

___________ ________________ _________________ _____________

___________ ________________ _________________ _____________
___________ ________________ _________________ ____________

List facilities in which you have served time:

Facility                                                               Supportive Persons                                Mentor Dates

___________________________ __________________________ __________________________

___________________________ __________________________ _________________________

___________________________ __________________________ __________________________

___________________________ __________________________ __________________________

Prison Jobs/Assignments _________________________________________________________________

FAMILY INFORMATION:
Family Status
Never been married _______ Married ___________Divorced__________ How many times married_______
Spouse’s name _____________________________ Spouse’s phone number__________________________
Spouse’s address_____________________________ City, State Zip Code _________________________
Children:
Name                                                              Age     Do you have contact with them and how?
___________________________ ____ ___________________________________________
___________________________ ____ ___________________________________________

___________________________ ____ ___________________________________________

_________________________ ____ ___________________________________________

Is your father alive? Yes___ No________                Is your mother alive? Yes____ No_____ _________________________________ _________________________________________
Name                                                                                    Name
__________________________________ ___________________________________________
Address                                                                                Address
__________________________________ ___________________________________________
City                State               Zip                                         City                State               Zip
__________________________________ ___________________________________________
Phone                                                                                   Phone

May we contact them on your behalf? _______        ________

Describe Relationship with Father                                Describe Relationship with Mother
__________________________________     _______________________________________

__________________________________     _______________________________________

___________________________________   _________________________________________

Any Living Brothers or Sisters?
Name ___________________Address___________________Phone_______________________
Name ___________________Address__________________ Phone_______________________
Name ___________________Address___________________Phone_______________________
Name __________________ Address___________________Phone_______________________

Is there a significant other (male or female) in your life? Yes__________ No_____________
Give name and relationship___________________________________________________________
Children? _________________________________________________________________________
List any other mentors, pastors, good friends with whom you wish to have a continued relationship, along with their addresses and phone numbers: ______________________________________________________
_______________________________________________________________________________________________________________________________________________________________________

Drug/Alcohol Usage:
Drug(s) of choice_________________________ Other drug usage___________________________
Current Length of sobriety from the above drugs ___________________________________________
Have you had other periods of sobriety? Explain___________________________________________

Have you ever done a treatment or 12 step program? Explain______________________________________
______________________________________________________________________________________

Are you affiliated with a particular gang? ___________________________________________________
Are any family members associated with a particular gang? _______________________________________

(This does not disqualify you from the program)

List any hobbies ______________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________

FINANCIAL INFORMATION:
Past child support owed? ___________ Currently monthly payment? _______________
Is there a court order for this? ______________
Explain______________________________________________________________________
Court Ordered Restitution or Fines? _________ How much? __________________
Any other debts or financial obligations that you have amounts and schedules of payments_______________________  _____________________________________________________________________________________

List all of your material resources and amounts to include things such as savings account balance, automobiles, life insurance, settlements, etc.___________________________________________________

How do you plan to pay the first month’s fees? _________________________________________________
______________________________________________________________________________________

Do you have a driver’s license?_______ Is your driver’s license clean? ____________________
Do you have a car?_______ What do you do for transportation?_______________________

List any fines, restrictions, required classes, or community service needing to be complete
__________________________________________________________________________________________________________________________________________________________________________

HEALTH:
Date of last physical or doctors appointment __________ While incarcerated? _________________
Diagnosis and treatment: ___________________________________________________________
Mental/Emotional problems_________________________________________________________
Treatment_______________________________________________________________________
Have you been tested for HIV or AIDS? Results_________________________________________
Have you been tested for Hepatitis? ________________________TB___________________________
Any other health problems that we should be aware of? _______________________________________
Are you under social security disability or applying for disability?______________________________
Do you consider yourself able to work? If no, why?________________________________________
Any special dietary needs? ___________________ Any prescription medications?_________________
Any allergies to medications?________________________________
Have you ever been in another rehabilitation program? If so, where and when? Inpatient/Outpatient
____________________________________________________________________________________________________________________________________________________________________________

Have you ever had impatient psychiatric care? If so, where and when? Diagnosis?____________________________

____________________________________________________________________________________

Do you anticipate continuing any mental health counseling/ with whom?_____________________________
______________________________________________________________________________________

EDUCATION:
Grade completed________ Age _________ Diploma or GED?___________________________
List all classes taken while in prison and grades received, Was the class completed?
______________________________________________________________________________________

______________________________________________________________________________________
MILITARY SERVICE:
Branch_____________________________ Date of Service __________________________

EMPLOYMENT HISTORY:
List all employers for 3 years prior to arrest:
____________________ _____________________ _______________                    _____________
Employer                                      Address                                         Dates (MM/YYYY to MM/YYYY) Reason for leaving

____________________ _____________________ _______________                       _____________
Employer                                      Address                                          Dates (MM/YYYY to MM/YYYY) Reason for leaving

____________________ _____________________ _______________ _____________
Employer                                     Address                                           Dates (MM/YYYY to MM/YYYY) Reason for leaving

Do you have any job prospects upon release? Or are you currently employed?______________________
____________________________________________________________________________________

As you look back on your time in prison (or your last couple years), what good things can you see that will help you now?
____________________________________________________________________________________________________________________________________________________________________________

Which of the following contributed to your incarceration (or current circumstances)? Identify the degree of negative influence, 1 being the least influential and 5 being the most strongly influential. RATE ALL AREAS with a number from 1-5
____alcohol    _____myself    ____friends, relatives, etc          ____lack of education
_____ poor decisions      _____ poor attitude     _____ poverty/homelessness       ____drugs/alcohol
___ pornography       _____ anger        ______ association       _____lack of motivation
_____ traumatic event in your life       ______giving up          _____ mental health

What are you doing to change the areas listed above? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________

WHY WOULD YOU LIKE TO BE ACCEPTED TO THIS PROGRAM?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

IS THERE ANY OTHER INFORMATION YOU WOULD LIKE US TO KNOW?

____________________________________________________________________________________________________________________________________________________________________________

___________________________________________ _______________________________
Signature                                                                                                        date

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For office use only:
Interviewed:
Manual Sent:
Next Court Appearance:

Persons contacted on applicant’s behalf:

Accepted:

Visits:

Questions/Comments: