Program Application

Fill out the application form below to take the first step towards joining our program. After submitting your application, our team will reach out to you promptly to discuss how we can assist you further. Your journey to stability and support starts here!

Are you a U.S. Citizen?

Are you able to read/write English well?

Where did you stay last night?

Release date for those in an Institution/ARC

How long have you been homeless?

Have you ever been baker acted? When?

How long have you been in Marion County?

Where is your nearest family?

Why are you homeless?

Write a few sentences about what brings you here/what happened.
Employment Status

If you are not currently employed, what was the last position held?

Why did you leave your last position?

Date of last position held

If not employed, are you currently looking for work:

If no, explain why:

Are you a Veteran?

Did you serve in a war zone?

Are you currently in the military?

List your service dates

Service Area:

Which military branch did you serve?

What type of discharge did you receive?

Are you disabled?

Have you been disabled for more than a year?

Check all disabilities that apply:

Substance abuse history:

When is the last time you used drugs or alcohol?

Would you pass a drug screen and breathalyzer?

Are you currently taking Buprenorphine (Suboxone) even if prescribed?

Have you ever been convicted of a felony?

Have you ever been convicted of a sex crime?

Have you served time in jail or prison?

If yes, how long:

Do you have any pending legal matters?

Are you currently on probation?

If yes, what is the date your probation expires:

Do you have legal fees/fines that you currently owe?

How would you rate your general health right now?

Do you have a regular doctor?

Are you currently taking any medications?

If so, list all medications that you are currently taking:

Is there medication that you are supposed to be taking but do not have it?

Do you have a psychiatric diagnosis?

Do you have any known allergies?

If so, what?

Do you currently use alcohol?

Do you currently use drugs?

Do you have a history of alcohol or substance abuse?

Have you ever received treatment for a mental health issue?

When is the last time you had a dental appointment/check-up?

Are you currently fleeing abuse?

Have you ever been a victim of domestic violence?

Open Arms Village at St. Mark’s United Methodist Church
Autherization for Background Check

1839 NE 8th Road
Ocala, FL 34470

(352) 304-6229