Section 1 : Applicant Information

First Name *

Last Name *

Date Of Birth *

Address

Street Address

State

City

Postal Code

Phone *

Emergency Contact Name *

Emergency Contact Phone *

Email *

What Program are you applying for ? *

Re-Entry

Sober Living

General Population

Section 2 : Housing Needs

1. What type housing are you seeking ? *

Yes

No

2. When do you need housing ?

Immediatly

Within 7 Days

Within 30 Days

Flexible

3. Are you currently homeless ?

Yes

No

4. Are u currently incarcerated ?

Yes

No

5. If incarcerated, what is your expected release date ?

Please Select the location & type of housing you are interested in. This does not gurantee you will be at this location. It is based on avaliability and your budget. *

Section 3 : Background Information

1. Have you ever been convicted of a felony ? *

Yes

No

2. Are you on probation or parole ? *

Yes

No

3. Do you have any pending legal charges ? *

Yes

No

5. Please explain any "Yes" answers above .

4. Are you required to register as a sex offender ? *

Yes

No

Do you currently or have you had any substance use/abuse history? *

Yes

No

If you answered yes to the above question, do you need substance abuse treatment/AA? *

Yes

No

N/A

Section 4 : Support Needs

1. Do you currently receive case management services ? *

Yes

No

2. Do you currently have a counselor , case manager , or social worker ? *

Yes

No

3. Counselor / Case Manager Name

4. Counselor / Case Manager Phone Number

5. Counselor / Case Manager Email

6. What support services are you currently receiving or need assistance with ?

common.other_option

Identification *

Proof of Income *

Section 5 : Health & Support Information

1. Do you have any medical conditions we should be aware of ? *

Yes

No

If yes please explain

2. Are you taking prescribed medications ? *

Yes

No

If yes please list the medications

3. Do you have any mental health needs or concerns that may require additional support ? *

Yes

No

If choose yes please explain

Section 6 : Income & Payment

1. Do you currently have a source of income ? *

Yes

No

3. Approximate Monthly Income *

$

4. Will you be responsible for paying for your housing ? *

Yes

No

5. Name of Paying Agency / Sponsor

6. Sponsor Contact Name

Section 7 : Program Rediness

1. Are you willing to follow all house rules and guidlines ? *

Yes

No

2. Are you willing to participate in all mandatory meetings ? *

Yes

No

3. Are you willing remain drug and alcohol free ? *

Yes

No

4. Do you understand that completing this pre-screen does not guarantee acceptance info the program *

Yes

No

5. Anything else you would like us to know while considering your application ?

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