APPLICATION 1

THE HOUSE OF GRACE APPLICATION FORM

The House of Grace is a safe and supportive environment for pregnant teens and young mums. We understand your circumstances are unique and your application will be considered on this basis.

Below is the eligibility criteria for residency at The House of Grace:
- Pregnant or have a new-born baby and are aged between 12 and 23.
- The young person applying to live in the home must do so of their own free will.
- Be willing to participate in daily activities of the home and educational programmes
- All residents are to be drug and alcohol free.
- All residents are to be smoke free.
- All residents must be respectful of each other at all times.

Please note: The young person applying to live in the home must participate in completing this form. Once completed, one of our team will contact you to discuss the next steps.

Your details

Date *

Name *

First name

Last name

Current address *

Address line 1

Address line 2

Address line 3

Address line 4

Town/Suburb

City

Postcode/Zip

Home phone

Mobile phone *

If you do not have a mobile phone, please put a number we can get hold of you.

Email address *

Confirm Email address

Your date of birth *

Age *

Ethnicity *

Due date / baby's birth date *

If you have a faith or culture you identify with, please let us know

If you attend a church, where do you go?

Please tell us about your current living arrangements *

Please tell us why you would like to live at The House of Grace *

Your health and past is important. We want to help you with where you are at. Do you have any history of the below? If yes, please provide dates and relevant information.

Drug and/or alcohol addiction/dependency *

Smoking *

Self-harm *

Suicidal thoughts and / or attempt *

Mental illness *

e.g. anxiety, depression, bipolar

Developmental or learning challenges *

e.g. ADHD, Autistm, foetal alcohol syndrome

History of aggressive / threatening behaviour or difficulty controlling your anger *

If yes, please provide details

Gang involvement or affiliation *

If yes, please provide deatils

History of committed crime and / or convictions *

If yes, please provide details

Who has custody/guardianship of you?

For applicants 17 years and under

Relationship of guardian

Guardian phone number

Is there an agency supporting your application to The House of Grace? Please advise:

Name of agency

Social workers name

Social workers number

Baby

Babys name (if born)

Baby's due date or date of birth *

Babys gender

Who has guardianship of your baby?

Are Oranga Tamariki involved? If yes explain the details of involvement

Child social workers name

Child social workers phone number

Are you and your baby's father in a relationship? If yes, please describe your relationship *

Birth fathers name

Birth fathers age

Birth fathers contact number

Birth fathers ethnicity *

Are there any restraining or protection orders in place? If yes explain the details

If you are within the criteria for residency, one of the team will contact you to discuss an intake interview at the home. This is an opportunity for you to view the home, meet the Housemother and discuss any questions you may have. Any decisions about a placement in the home will be made after that.

* You can view our privacy statement on The House of Grace website: www.thehouseofgrace.org.nz to find out how we manage your personal information *