Assessment

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Fill this assessment out completely and hit "Submit" at the bottom of the page. Make sure you leave a good contact so we can follow up.

Date Wanting To Come In And Stay*

First name*

Middle Initial*

Last Name*

Phone Number*

Contact Preference*

Phone

Birthdate*

County of Residence (must provide proof)*

Hancock

Henry

Fayette

Rush

None

How Long Have You Been Homeless*

Reason For Homelessness*

Income*

Full-time (30 plus hours a week)

Part-time

Disability

SSI

No Income

Are You Currently Incarcerated*

Yes

Do You Have Any Criminal Charges Sexual In Nature*

Yes

Are You Currently*

On Probation

On Parole

On House Arrest

On Drug Court

Does Not Apply

Do You Have Any Serious Health Conditions*

Yes

Have You Been Prescribed Medication For Mental Illness*

Yes

Are You Currently Taking All Medication Prescribed For Mental Illness*

Yes

Does Not Apply

Can You Climb Steps & Practice Personal Hygiene Independently*

Yes

Do You Have A State ID or Jail ID*

Yes

I understand while I am In Life Skills, Recovery, or Vocational programs I will be required to attend weekly religious services. This does not apply while in Emergency Shelter program.*

I Understand

I understand I must stay in Emergency Shelter for 14 days before additional programming will be offered.*

I Understand

Get in touch

First Name*

Last Name*

Your email*

Subject*

Message*

The Guest House

1407 Walnut Street
New Castle, IN 47362

(765) 388-2136
info@theguesthousenc.org

Assessment

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The Guest House

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