Applicant Full Name *
Applicant Email *
Current Address *
Applicant Phone Number *
Application Date *
What location are you applying for? * Schieffer Ave. House
Who referred you? How did you hear about us? Please include name of person or agency and phone number. *
Who is this application for? * Myself Family Member Client (I am - Case worker, referral agency, social worker or sponsor)
Gender * Male Female Transgender Female Transgender Male
Date of Birth *
Age *
Weight *
Height *
Have you served in the military? * Yes No
Are you pregnant?
* Are you aware that this is a shared living home? * Yes No
Have you lived in shared housing before? * Yes No
Are you able to live independently without assistance with daily activities including cooking, cleaning, bathroom use, activities outside the home, taking medication, etc? If not, please explain what you need assistance with. *
Current Living Situation * Group Home/Shared Living Living with family Living by myself Living with roommates Living in a motel Homeless with no permanent place to live
Funding Source
* How long would you like to be a guest at our home? * 1- 3 months 4 - 6 months 7 - 12 months 1 - 2 years
If you receive a voucher, what is the voucher 's name? If this doesn't apply to your situation put N/A. *
Are you employed? * Yes No
If you are employed, what are your hours/shift? What city do you work in? *
Employer Name? N/A if unemployed. *
If not employed, do you intend to apply for a job within 1 month of your arrival at our home? * Yes No
If you don't intend on working or going to school, etc. please explain why not and what you plan on doing with your daytime hours? *
A Representative Payee is required for SSI and SSDI payments to ensure timely monthly housing payments are made during your stay in our home. Do you agree to this? * Yes No
Criminal History * I have a felony I have a misdemeanor I have no criminal history
If yes, please provide details of any criminal charges or convictions you have, including the nature of the charges and any associated legal outcomes. *
Do you have a probation officer, etc? If so, what is their name and phone number including extension? *
Funding Source Details: 1. What is the monthly income that you receive? *
Funding Source Details: 2. What is the specific date that your payment is disbursed? *
Funding Source Details: 3. Any additional income information? *
Please disclose any existing medical/mental conditions or health concerns that we should be aware of. What have you been diagnosed with, if any? *
Do you have any food or drug allergies? If yes, please elaborate. *
Are you currently attending Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings? If yes, please specify which one(s). If no, do you need to find a meeting to attend? *
Are you currently taking any medications? * Yes - prescription medication Yes - over the counter medication No
If yes, please provide a list of the medications you are taking, including their names and dosages. *
Are you currently taking any medications as part of your recovery treatment? If yes, please specify which one(s). *
Do you have a sponsor or are you/will you be actively seeking one? (Please specify) *
How long have you been in recovery? Please provide details about your recovery journey. *
Are you involved in any other support groups or programs related to recovery? *
Have you completed any rehabilitation or treatment programs? If yes, provide details. *
Are you coming from another group home? If yes, please specify which one and for how long you've been living there and the reason for living. *
Do you have a history of relapse? If yes, please provide details and specify if you have a relapse prevention plan in place. *
Do you have any specific needs or requirements related to your recovery journey that you would like us to be aware of? *
Primary Mode of Transportation * Public Transportation Personal Vehicle
Do you smoke? * Yes No
If yes, what do you smoke? *
Do you have any pets? * Yes No
Do you agree to a drug test prior to your move-in date? * Yes No
Do you agree to random drug tests? * Yes No
We have house rules to govern the safety and harmony of the home. Would you abide by them? * Yes No
Preferred Move-in Date *
Any important details we should be aware of, not yet addressed? *
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