PLEASE FILL OUT THIS FORM ON A COMPUTER.

CLICK ON A LINE AND TYPE YOUR INFORMATION.

PRINT 2 COPIES WHEN COMPLETED, ONE TO SUBMIT
TO US AND ONE TO KEEP. YOU WILL NOT BE ABLE TO
SAVE THE ENTRIES MADE ON THIS FORM; ONCE YOU
CLOSE IT, YOUR DATA WILL DISAPPEAR. REMEMBER
TO SIGN AND DATE IT AT THE END.

Bayside Cottage
83B School Street, Hyannis, MA 02601
Btohope2005@gmail.com

BAYSIDE COTTAGE APPLICATION

Name: ________________________________________________________
Age_____ Date of Birth: _____/_____/_____Social Security No: _____/_____/______
Is your Mass Health in good standing? Y_____N_____
Are you claiming SSI/SSDI? Y______N______
Parole date: ____________ Probation: _____________ End date_________________________
Time served_________BCCF________BRISTOL________FRAM______OTHER_______
Reason for incarceration:_________________________________________________________
______________________________________________________________________________
Length of sentence____________Date sentenced______________________
Is this your first incarceration? Y____N_____How many times?__________________________
Reason:______________________________Where:___________________________________
Have you ever been on parole? Y________N________Year(s)?________________
What is your release date?____________________
Community Service?_____________________Open cases?______________________________
Outstanding court fees?____________________________Restitution______________________
Address prior to incarceration______________________________________________________

ADDICTION HISTORY
List all drugs used and age used____________________________________________________
______________________________________________________________________________
How old when first used?________________What did you use?__________________________
List all treatment programs attended/year_____________________________________________
______________________________________________________________________________
______________________________________________________________________________
Complete program? Y_____N_____ Name/When/How long?__________________________
______________________________________________________________________________
Date of last use________________
Sober outside of jail/program?Y_____N_____ How long?_______________________________
How/why did you do it?__________________________________________________________
______________________________________________________________________________
Ever been to AA/NA?_____If no, why not?__________________________________________
Ever been to individual counseling/Gosnold IOP? Y__N__When?_________________________
How often? ____________________ Sponsor? Y_____N______

MENTAL HEALTH HISTORY

Have you been treated for mental or emotional problems? Y_______N_______

Diagnosis: ____________________________________________________________________
Taking prescribed medication? Y______N______
Medication prescribed____________________________________________________________
Doctors name/address___________________________________________________________

Ever hospitalized for mental/emotional problems/suicide attempts?

When/where___________________________________________________________________
Have you ever been diagnosed with a mental/developmental disability?____________________
______________________________________________________________________________
______________________________________________________________________________
How do you handle stress/anger?___________________________________________________

FAMILY INFORMATION

Marital status: Single_______Married_________Separated_________Divorced_________

Spouses name:_________________________________________________________________
Restraining orders/harassment issues?_______________________________________________
Are you in a relationship?_________________________________________________________
Names/ages of children___________________________________________________________
Current living arrangements w/ children_____________________________________________
Emergency Contact:______________________________Relationship to you?______________
Address:_________________________________________Phone:_____________________
MEDICAL INFORMATION
Do you have a Primary Care Dr.? Y______N______If yes, date last seen_____________
Dr. Name/Phone Number_________________________________________________________
Dr.Address____________________________________________________________________
Allergies?_____________________________________________________________________
______________________________________________________________________________

Past medical issues______________________________________________________________

______________________________________________________________________________
Present health issues_____________________________________________________________
______________________________________________________________________________
EDUCATION & JOB HISTORY
Highest Level of Education: GED ___, HS Diploma ___, College ___, Other ___
Special training_________________________________________________________________
List last 3 jobs held/title/how long employed:
1_____________________________________________________________________________
2_____________________________________________________________________________
3_____________________________________________________________________________
Have you ever held a job while you were clean and sober?___________________
What are your education/job goals?_________________________________________________
______________________________________________________________________________
FAITH
What, if any, is your faith background?______________________________________________
______________________________________________________________________________
Do you believe in God?__________________________________________________________
Present faith?___________________________________________________________________
Do you pray?___________________________________________________________________
In the past, what Christian activities have you been actively involved in?
______________________________________________________________________________
Which religious programs have you attended in jail?____________________________________

MOVING FORWARD
What do you believe are your strengths?_____________________________________________
_____________________________________________________________________________
What do you believe are your weaknesses?___________________________________________
______________________________________________________________________________
Who is a safe support person for you right now?_______________________________________
______________________________________________________________________________
Briefly in your own words, explain why going to a program would be different for you?

Where do you see yourself in 6 months?

Affirmation:
I hereby make application to Bayside Cottage and understand that I must have a Bridge to Hope
mentor in order to be accepted to Bayside. I also hereby release this information for use in
making a decision about my acceptance. I certify that the information contained in this
application is true and complete. I further understand that any false statements or
misrepresentations made by me on this application or any supplement thereto will be sufficient
ground for rejection of this application or discharge from Bayside Cottage. I have read the
Bayside Cottage Program Contract and agree to willingly abide by the requirements. I further
understand that Bridge to Hope is a faith-based mentoring and housing ministry with Christian
values and expectations for my behavior.

________________________________________
Signature

________________________
Date