Assessment

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Services
You Can Help
Thrift Store
Contact
2024 Fundraiser

Home
About
Services
You Can Help
Thrift Store
Contact
2024 Fundraiser

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

Contact Person*

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 you are a faith-based transitional sober living facility that also offers emergency shelter.*

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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