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About Us
Our Programs
Seek Shelter
Contact Us
Donate

El Shaddai Homes
505 W. Temple Ave.
PO Box 6065
Effingham, IL 62401

(217) 663-5293-Director
(217) 690-4380 - House

A place for you

Apply to El Shaddai Homes

Personal Information

Full Name *

Email Address *

Phone *

Sex | Race *

Birth Date *

Hair Color | Height | Weight | Eye Color *

Birthmarks or Identifying Characteristics

Housing *

I currently reside in a home.I currently stay in a shelter.I am currently homeless.I am staying with friends or family.

Write a brief description of why you are seeking placement at El Shaddai Homes *

Religious Affiliation *

Health History

Family Physician Name *

Primary Dr. Phone *

Any ongoing health problems? *

List any hospitalizations *

Check any that apply to you *

Past Drug UseCurrent Drug UsePast Alcohol UseCurrent Alcohol UseNone of the apply to me

Do you have a court record? *

YesNo

Are you currently taking medication? *

YesNo

If you answered yes above, please list any medications you are currently taking (include dosage) *

Do you have any allergies? *

YesNoI don't know

If you answered yes above, what are your known allergies? *

Pregnancy

OB/GYN Name *

OBGYN Phone *

Your Due Date *

Have you taken drugs since pregnancy? *

YesNo

Do you know the biological father of the baby? *

YesNo, I don't know

Is the baby's father involved? *

YesNo

Please check if you are covered under any of the following *

LinkWICMedicaid

Number of Pregnancies *

Number of Living Children *

Consent *

I understand that El Shaddai Homes will review my application and that submission does not guarantee approval.

By submitting, I attest to the following:

All information provided is true and accurate.
I will take an active role in my success by attending case reviews, following house guidelines, and engage fully with my treatment plan.

El Shaddai Homes
505 W. Temple Ave.
PO Box 6065
Effingham, IL 62401
(217) 663-5293-Director
(217) 690-4280 - House