Dismas Application
PLEASE FILL OUT COMPLETELY & RETURN APPLICATION TO:
Dismas House, Post Office Box 30125, Worcester, MA 01603
Phone (508) 882-0000{no collect calls accepted} DO NOT FAX!
NAME:______
(Last) (First) (Middle) (bracelet/prison numer) (Institution)
Birth date:____/____/____ Birthplace______Social Security #______
(City) (State)
Race/ethnicity (s):______Driver's License # ______
Last Residence______
(Address) (City) (Country) (State)
Whose address is this?______
NEXT OF KIN: Name:______Relationship:______
Address:______Telephone:______
One other person who will always know how to contact you?
Name:______Relationship:______Telephone:______
Address:______
What are your debts?______
Do you have savings or income?______
Marital Status______Names and ages of children______
______
Status of your child support/child custody?______
In regular contact with spouse or significant other (s)?______
Children?______Parents/Family?______Other?______
GOALS:
What are your short term goals? (1-3 months)______
______
Medium range goals (3-6 months)______
______
Long range goals (1 year +)______
______
HEALTH:
Have you ever been diagnosed for any physical health problem?______
List treatment received:______
Are there any medications you regularly take? List them:______
Are there any other health problems that would prevent you from working?______
Have you been diagnosed, or do you believe that you have any mental health problems?______
______
Treatment received:______
RECOVERY HISTORY:
Do you believe you have a drug or alcohol problem?______
Are you an alcoholic and/or drug addict?______
List primary drugs of use, method of intake and age at first use:
1.______
2.______
3.______
What treatment have you received in prison?______
______
What treatment have you received on the streets? (i.e. counselors, meetings, other programs)______
What is the longest period of sobriety you have had on the streets?______
How long have you been sober now?______
What is your specific plan for recovery?______
______
EDUCATION:
Last grade completed:______GED (Place and date):______
College/Trade School:______
(Location, Hours Completed, Degree Sought)
Military Service?______Combat Experience?______
EMPLOYMENT:
Last Company:______Address:______
From:______To:______Why did you leave?______
Describe job:______
Were you employed at the time of most recent arrest?______
What kind of work do you do?______
What kind of work, training, or school would you like to do?______
______
What is the longest time you've held the same job?______
What are your credit problems:______
CURRENT CHARGES:______
CURRENT CONVICTIONS:______
Alcohol/drugs prior to (or during) crime? ______
Alcohol/drugs in prison?______
Current sentence?______Date incarcerated, this offense:_____/_____/_____
Did you know the victim?______How?______
Expiration of sentence date: _____/_____/_____
Next parole hearing: _____/_____/_____ Earliest release date: _____/_____/_____
List and date all disciplinaries:______
______
Prison Job:______Prison Programs:______
Past prison programs:______
Prison Employee, Volunteer, or other Community References:
Name Position Phone Number Number of Years Known
______
Who is your counselor or caseworker? ______
*****WHAT IS YOUR CASE WORKER’S NUMBER?****______
PAST RECORD:
Your age at first arrest?______Juvenile record?______
(List all arrests and convictions)
______
In Juvenile Facilities?______How long?______
All Prior ADULT arrests, charges:______
______
All Prior ADULT convictions:______
______
How much of your adult life has been in prison/jail?______
Federal/Out-of-State charges and convictions?______
______
ADDITIONAL INFORMATION:
Have you ever applied to/lived in a Dismas House?______Which one?______
Hobbies:______
THE STATEMENT BELOW MUST BE READ, UNDERSTOOD, SIGNED AND DATED.
I agree to stay at Dismas Family Farm for at least 90 days. I will live in community as described in the fact sheet that I have received. I give permission for Dismas to see any information in files kept on me by the Dept. of Corrections or by any other agency. I understand this information will be kept confidential by Dismas. Twenty one days after termination of my stay at Dismas Family Farm, the staff will dispose of any property left.
SIGNATURE:______DATE:______
DISMAS HOUSE DOES NOT DISCRIMINATE APPLICANTS ON THE BASIS OF GENDER, RACE, SEXUAL ORIENTATION, NATIONALITY OR RELIGIOUS CONVICTION.