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Step 1 of 10 - Personal Information

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Name(Required)

First Last

Age(Required)

Please enter a number from 0 to 120.

Phone(Required)

Email(Required)

Are you a victim of domestic violence? Are you in currently in danger?(Required)

Yes

If you are currently in danger, please contact the Self Help Center immediately at (307) 235-2814. Seton House is not a safe house or a domestic violence shelter. We are not able to house or protect someone in danger.

Marital Status(Required)

Single

Married

Divorced

Separated

Widowed

Have you ever lived at Seton House?(Required)

Yes

If yes, when?(Required)

Why did you leave?(Required)

Do you know someone who currently lives at Seton House? If yes, who?(Required)

Do you have any children in your care?(Required)

Yes

How many children do you have? How many are in your care?(Required)

Age/Gender of children

Do your children live with you?(Required)

Yes

If no, where do they live?(Required)

Do you have shared custody of your children?(Required)

Yes

If yes, please tell us about the custody arrangements:(Required)

Currently Pregnant?(Required)

Yes

If yes, when are you due?(Required)

MM slash DD slash YYYY

Are you involved with a DFS case?(Required)

Yes

If yes, who is your case worker?(Required)

If a DFS case plan in in place, please tell us where you are in the reunification process:(Required)

Where are you currently staying?(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Where are you working?(Required)

In no, please write unemployed.

If you are not currently working, are you capable of working?(Required)

Yes

Do you have a valid driver's license or state issued ID?(Required)

Yes

Do you own a vehicle?(Required)

Yes

Are you currently on probation/parole?(Required)

Yes

Are you on drug court?(Required)

Yes

Who is your probation/parole officer?(Required)

Please list other agencies with whom you are involved and your case manager at those agencies:(Required)

In your own words, please tell us what your reason is for coming to Seton House and what you hope to gain from this program.(Required)

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You may also download the PDF version of the inquiry below.

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