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You Matter

At Tried by Fire Inc., we are dedicated to empowering individuals through innovative solutions. Our focus is on supporting My Sisters House, fostering resilience and growth in our community.

Conditions of this Application

Basic Information

Please answer all questions as thoroughly and honestly as you can. Do not leave any areas blank; if the question does not apply to your situation put N/A.

Date of Application*

Month

Day

Year

First name*

Last name*

Present Address*

Phone*

Second Contact Phone

Email

ID or Drivers License Number*

Upload a copy of your ID or DL*

Birthday*

Month

Day

Year

Social Security Number*

Marital Status*

If married, your spouse's name

Do you have children:*

If yes, how many and list their names and ages

Emergency Contact Names and Telephone Numbers*

Ethnicity*

Do you consider yourself religious?*

Yes

No

Do you attend church?*

Yes

No

Name of Church and Pastor Name and Phone Number*

Substance Abuse

List all substances that you have used and the last time you have used each:*

Have you ever used IV drugs not prescribed?*

Yes

No

When was the last time?*

Month

Day

Year

Have you ever been dismissed from a treatment program or a recovery home*

Yes

No

If yes, please describe the situation that led to your discharge:*

My Sister’s House is not a medical facility and does not staff medical professionals. Therefore, you must be detoxed (drug and alcohol free) for a minimum of 7 days prior to your arrival. Do you agree?*

Yes

No

What is your plan to detox and remain drug and alcohol free for the 7 days prior to arrival?*

Legal

List all current legal issues including court dates:*

Are you under bond? *

Yes

No

County & State of your bond:

Are you a registered sex offender? *

Yes

No

Are you on probation? *

Yes

No

Do you have a Probation Officer? *

Yes

No

Probation Officer Name, Phone Number, and Fax

Currently paying child support or alimony? *

Yes

No

Do you have an attorney?*

Yes

No

Attorneys Name and Phone Number*

Are you ordered to complete a treatment program by a member of the court, resulting judgment or probation officer*

Yes

No

If yes, please explain:

Medical

List all medical issues including: bi-polar, handicapped, schizophrenia, seizures etc. *

List all medications that you are currently prescribed: *

List all medications (over the counter) that you take on a regular basis:*

Have you ever attempted suicide? *

Yes

No

Currently Considering Suicide

Have you ever had convulsions, seizures, or blackouts? *

Yes

No

List any allergies*

Do you have heart disease, diabetes, epilepsy or respiratory disease? *

Yes

No

List doctor name, phone, and fax number*

Enter you Medical Insurance Name, Phone Number, and Policy Information. *

Conditions of this Application*

My Sisters House CLICK ON THE LINK TO READ THE CONDITIONS

Sign here to authorize “My Sister’s House” staff to consult with your Probation Officer and/or your attorney regarding your legal situation and that you have read the Conditions of the Application.*

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