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Refuge House Application

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  1. Fill out the application below.

  2. Make an appointment to see your physician and see him/her as soon as possible.

  3. Click here for Physician Forms. Take these 5 pages to your next doctor’s appointment or email them to your physician.

  4. The following 5 tests need to be done at your doctor’s appointment or scheduled at a lab. Your doctor’s office will fax your completed test results directly to Refuge House.

  • TB

  • HIV

  • STI testing/history

  • COVID-19

  • Basic drug panel

“For I was hungry and you gave me food, I was thirsty and you gave me drink, I was a stranger and you welcomed me, I was naked and you clothed me, I was sick and you visited me, I was in prison and you came to me.”

​​Matthew 25:35-36 (ESV)

Housing Application

Do you feel safe?
Are you experiencing domestic violence?
Do you drive?
Do you have your own vehicle?
Is this pregnancy considered high risk?
Do you have other children that live with you?
Is he supportive of you and this pregnancy?

Financial

Check if you have any of the following:
Please check any sources of debt you may have:

Previous Residences

Were you ever in foster care?

The above information is for confidential purposes only. It will not be shared.

Refuge House and its location must remain confidential for the protection of all of our residents. Thank you.

Physical Health

Check if you have or have had in the past any of the following:
Check if you have any of the following mental health conditions:
Does having any of these diagnoses affect your daily living or coping skills?
Do you have suicidal thoughts?
Have you ever been treated in a psychiatric hospital?
Have you ever been in treatment for substance use disorder?

We will schedule a meeting with you to review your application as soon as we receive your portion of the application, the physician’s portion of the application and the test results.

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