Brook Haven House

PO Box 44
Carthage NY 13619

Attn: Board of Directors

Application for Admission

Name:                                                                              
Date of Birth:                                                                     
Current Address:                                                                                                                                                                                                                                                                     

Phone #: (    )                                          
Martial Status:                                                      If Divorced When:                                       
Years Married:                            
 
Emergency Numbers to call:  _____________________________________________
List two people other than your parents to call in case of an emergency, give Names, Addresses, Phone Numbers and Relationship to you.
            1) __________________________                2) ___________________________
                 __________________________               _____________________________
                 __________________________               _____________________________
                 __________________________               _____________________________
                 __________________________               _____________________________
 
 
Family Background:

1. Give a brief description of your childhood years and the personal benefits, challenges and struggles you personally faced as you grew up in your family.
2. Give names, dates of birth and education of yourself and siblings.
3. Do you have other children?  If yes please give names, ages, and where they are staying at the present time.
4. Give a brief description of your current personal needs, which have led you to enroll in this program.
5. List any of your extended family members of friends who have been a support to you and give a brief description of how they have helped you in the past.
6. What goals have you set for yourself in the next year?  Please explain these goals and how you plan to obtain them.  You need to explain two goals.  These goals may include educational, personal, spiritual, financial, relational and reconciliation with family or friends.
7. What type of help do you feel you need.
8. Do you believe your extended family and/or father of your child will support and encourage your decision to enroll in BHH? Why or Why not.
9. Are you presently involved in a church?  If yes please give the name and phone number of your Pastor.
10. Why do you want to come to BHH?
     

List your caseworkers names and phone numbers.
 
Legal Status:

1. Have you ever been arrested/incarcerated? If yes, check all that applies to you:

a.       Felony

b.      Misdemeanor

c.       Juvenile Hall

d.      County Jail

e.       Prison – (State, Federal)

f.        Other:

2. Give a brief description of arrests and incidents checked in # 1.
    
        
3. Do you currently have a parole or probation officer who is working with you?  If yes please give name and phone number.
    
         
4. What were you arrested in connection with?
    
         
5. How do you see your coming to BHH helping you?

Financial Information:

1.      I am currently meeting my financial responsibilities through the following process:

a)      Full or Part time work

b)      Medicaid

c)      Social Security

d)      Unemployment

e)      WIC

f)        Food stamps

g)      Disability Family Assistance

h)      Medicare

i)        Child Support

j)        Others

2.      What financial goals do you hope to work toward during your time in this     program?

3.      How do you plan on paying your financial obligation to BHH each month, ($250.00)?
 

General Information

1.      Have you ever lived in a residential program, Rehab? Center, etc. before?  If yes, what was your reason for leaving?

2.      After reading the Residential Handbook please list any areas that you think you will have a difficult time following.

3.      What will be your biggest challenge if accepted at BHH?

 
To the best of my ability, I have provided accurate information on this application.  If accepted into this program, I am willing to work on the goals I have listed on this application.  I will continue to set new goals for my baby and myself as responsibilities continue to increase.  I realize this will not be easy but with the help of others I will try.  I also understand that I may not like what others think is good for me, but I will try anyway.  I realize that if I do not comply with the guidelines at BHH I will be asked to leave and will need to do so with in 72 hours.
 
Applicant Signature:                                                                               Date:                          
House Parents Signature:                                                                       Date:                          
Board Presidents Signature:                                                                   Date:                          
Parent or Legal Guardian:                                                                      Date: