The RefineryA Faith-Based Mission for Men

Emergency Housing

This application is the first step in seeking emergency housing.

Website

Applicant Information

First Name*

Last Name*

Current City*

Current State/Province*

Current Zip Code*

Social Security Number*

Are you a Veteran?*

Yes No

Are you a Registered Sex Offender?*

If you are, you aren't eligible for our program.

Yes No

Are you physically capable of climbing into a top bunk?*

Yes No

Are you willing to contribute here?*

We require you to participate in chores, work detail, and faith-based services. Once you start working you’re required to contribute financially.

Yes No

Do you have a Valid Driver's License?*

Yes No

Date of Birth*

City of Birth*

State of Birth*

Marital Status*

Race*

Highest Level of Education Attained?*

Are you Employed?*

Yes No

Monthly Income*

Source of Income*

Why do you need housing?*

Explain your current situation*

Your phone number / other way to contact you*

Email

Emergency Contact Information

Emergency Contact First Name*

Last Name*

Relationship to You*

Phone Number*

Street*

City*

State*

Zip*

Referral Source Information

If you’re coming from a Hospital, Prison, Jail, or Rehab, you must have the following when you arrive: (1) One month supply of medications; (2) If diagnosed with a mental illness, a follow-up appointment at a local mental health office; (3) No Narcotic Pain Medications or Controlled Substances (Lortabs, Xanax, Benzos, Suboxone, etc); (4) Approved Psych Meds are allowed.

Are you being referred?*

If referred, Name of Person Referring You

If referred, Name of Organization Referring You

Referring Organization/Person's Phone Number

Applicant Health Information

Applicant's Health Condition*

Do you have a disabling condition?*

Disability Type

Answer "NA" if you don’t have a disability.

Do you have a mental illness?*

If yes, please explain

Answer "NA" if you don’t have a mental illness.

What insurance do you have?*

List Prescribed Medications

Answer "NA" if you aren’t prescribed any. List what they are prescribed for. No Narcotic Pain Medications or Controlled Substances (Lortabs, Xanax, Benzos, Suboxone, etc).

Alcohol and Substance Abuse Information

Have you struggled with Drug Addiction in the past?*

Yes No

Have you struggled with Alcohol Addiction in the past?*

Yes No

Briefly Describe Addiction Background

Answer "NA" if you don’t have a history of substance abuse.

Can you pass a drug/alcohol screen?*

If you can’t pass a screen when you arrive, you will still be allowed to stay but can’t leave our facility until you can pass one. If you are dishonest about your usage on this application you won’t be allowed to stay at intake.

If No, please list drugs that you would fail for.

Answer "NA" if this doesn’t apply to you.

Court, Parole, Probation Status

Are you on Parole/Probation?*

Yes No

If yes, what were you charged with?

Answer "NA" if you don’t have a criminal history.

If yes, what is your DOC#?

If yes, please explain.

Answer "NA" if you don’t have a criminal history.

Previous Residency Information

Where are you currently staying?*

Length of stay at prior residence?*

Have you ever been a resident of the Refinery Mission?*

This also includes our previous organization name, the Opelousas Lighthouse Mission.

Yes No

If yes, did you leave on good terms?

If yes, what month and year?

Answer "NA" if you’ve never been here before.

Fields marked * are required. Need help? Call (337) 948-8865.

The Refinery Mission does not discriminate on the basis of race, color, age, ethnicity, religion, national origin, sexual orientation, marital status, disability, or status as a U.S. veteran.

704 W South St, Opelousas, LA 70570 · (337) 948-8865