Mary's House Application

Mary's House is a refuge where women battling life-controlling issues can come find healing in a Christ-centered environment. It is a place to cultivate connection; connection with a loving Father, connection with oneself, and connection with others. It is a place full of HOPE!

Fill out the application below to begin your journey to a new life. Please ensure the phone number you provide is one we can easily reach you at. After reviewing your application, we will give you a call to set up your interview. If you have any questions, please call us at 336-376-5066.

Name

Birthdate

This address will receive a confirmation email

Phone

Address

Marital Status

Please select one option.

Single Married Separated Divorced Widowed

Do you have children?

Please select one option.

Yes No

Child(ren)'s name

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone

Relationship

Emergency Contact Address

Medical Information

Do you have any food/pet allergies?

Please select one option.

Yes No

List allergies below

Do you have any ongoing medical issues?

Please select one option.

Yes No

List ongoing medical issues

Are you currently taking any medications?

Please select one option.

Yes No

List medications

What are the medications for?

Drug of Choice

Tell us how we can best help you. What are you struggling with? What do you hope to gain by being at Mary's House?

Are you ready to make this life-long commitment to change your life?

Please select all that apply.

Yes No

Mary's House Application

Description

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