Lighthouse Application

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Email *

What is your legal name? *

Do you go by this name or do you have a nickname you go by? *

What is your date of birth? *

YYYY

Current Address: *

Current Phone Number: *

YOUR BACKSTORY

This part of the application helps us know the parts of your history that make up who you are. Be as complete as possible so that we can match our resources to your needs.

MEDICAL

This section is for medical history only. There will be additional sections addressing psychological, spiritual, relational, legal, and occupational histories.

Please list any medical diagnosis or conditions that you have been treated for or are currently dealing with: *

Please list your current medications: *

Are you supposed to be taking any medications currently that you have opted not to take, do not have access to, or are currently not taking? *

Do you have any medical conditions that prohibit you from earning a living or performing daily activities? *

When was your last physical or doctor visit? *

Describe your physical health goals: *

PSYCHOLOGICAL

Have you been diagnosed, treated for, or struggled with any of the following? Check all that apply. *

Anxiety

Bipolar

Borderline Personality Disorder

Chemical Dependency/ Addiction

Depression

Eating Disorder

Obsessive Compulsive Disorder

PTSD/ Complex PTSD

Schizophrenia

Self Harm

Suicidal Ideation

Other:

Required

Are there other psychological issues you deal with or have dealt with in the past that are not listed above? *

Which of the following experiences have you survived? Check all that apply. *

Physical Abuse

Emotional/ Mental Abuse

Sexual Abuse

Sexual Assault

Rape

Suicide Attempt

Suicide of a Loved One

Violent Death of Loved One

Violent Crime

Required

What have you tried using to address these issues? *

Therapy

Self-medicating

In-patient treatment

Out-patient treatment

Classes, books, online content, self-education

Hospitalization

Organization or group (AA, NA, CoDep, ACA, etc)

Required

Describe your experience as to your success in dealing with these hurdles up to this point: *

Describe any goals you have for your psychological health: *

RELATIONAL/ SOCIAL

What types of relationship issues have you dealt with? Check all that apply. *

Foster Care- part or all of childhood in foster care or kinship placement

Foster Care- my children have been removed from the home at some point or currently

Have been a caregiver of minor, parent, or sibling while still a minor

Involved in codependent relationship (past)

Involved in codependent relationship (current)

Involved in violent relationship (past)

Involved in violent relationship (current)

Required

Check any of the following that apply to you currently or past relationships you have been involved in: *

Single (currently)

Single parent (children residing with me)

Single parent (children not in the home)

Married (currently)

Divorced

Widowed

PFA against another

PFA against self

PFS against another

PFS against self

Involved with or married to a violent offender

Involved with or married to a sex offender

Required

Describe your current core relationships. Include relationships you have with a significant other, children, parents, siblings, etc. *

Do you have children in the foster care system now? If so, please explain the situation. *

Describe any toxic, abusive, or codependent relationships you are currently involved in or have been involved in. *

What are your relational goals? How would you like your most important relationships to function or look? *

SPIRITUAL

Describe your history with spirituality up to this point: *

What is your view of God? Do you picture God as a grandpa? A harsh task-master? Gentle and loving? Disconnected and confusing? *

Do you have a relationship with Jesus Christ? *

What do you believe about the Holy Spirit? *

How do you think your spiritual life can strengthen you? *

What spiritual doubts do you have? *

Do you believe that you have any spiritual gifts? *

Describe what you would like your spiritual life to look like: *

OCCUPATIONAL

Describe your work history. Include types of jobs, about how long you were at each job, and why those jobs ended. *

Do you have any special schooling or training? *

Are you currently employed? Explain. *

What are your schooling or employment goals? *

What types of work are you passionate about? *

LEGAL

Have you been arrested? If so, when and for what? *

Have you ever been convicted of a misdemeanor or felony? If so, explain. *

Are you currently on Corrections? If so, explain. *

Do you have any current cases? Explain. *

Are you a registered sex offender? *

Yes

Have you ever struggled with or been convicted of arsen? *

Yes

LIGHTHOUSE

What are you interested in?

Residential

Nonresidential

Classes

Clear selection

Why are you reaching out to Light Up The Dark? *

How did you find out about Light Up The Dark? *

Based on past experience and history, where do you see yourself in two years if you stay on your current course? *

Where would you like to see yourself in two years? *

For everyone’s success, Light Up The Dark discloses that we are a privately funded 501c3 non- profit. We will evict anyone not honestly and actively participating in their own recovery as set forth by Lighthouse. Light Up The Dark and Lighthouse does serve as a safe haven and refuge for the sexually assaulted and abused people. Members do interact with each other. As a result, Lighthouse is unable to offer residential membership to registered sex offenders. Light Up The Dark reserves the right to refer a member to a more appropriate treatment facility for healing immediately if deemed necessary. If a member becomes a safety threat to themselves or others, Light Up The Dark will notify proper authorities and all necessary steps will be taken to ensure the safety of everyone concerned. Members will agree not to be involved in a romantic relationship with each other while participating in Lighthouse. Lighthouse is not a free housing shelter. All participants in Lighthouse are considered probationary members until employment is secured. Lighthouse participants must find employment in the first 2 weeks in order to secure full term participation in Lighthouse. If employment is not secured and/or sufficient efforts have not been made in the first 14 days, members may be referred to a shelter. For applicant: I realize that the Lighthouse to which I am applying for residency has been established in compliance with the conditions of §2036 of the Federal Anti-Drug Abuse Act of 1988, P.L. 100-690, as amended, and that as such Lighthouse (A) absolutely prohibits all participants in the program from using any alcohol or illegal drugs, (B) will expel any resident who violates such prohibition, (C) shares household expenses including and house lease/rental payment, among all residents, and (D) uses democratic decision making within the group. In accepting these terms, I, the applicant, understand that §2036 conditions are different than the normal due process afforded by some local landlord-tenant laws and by signing, I understand and acknowledge that I release myself from landlord-tenant laws. I understand and acknowledge that I may be evicted immediately pursuant to Lighthouse guidelines as stated in the Lighthouse House Manual. I support that all residential members only gain residence after agreeing to the residence and participation policies as stated in the Lighthouse Manual so that the climate and culture of the house supports my healing and sobriety as well as the healing and sobriety of other residents.
*

I understand and agree.

I understand but do not agree.

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