Housing Application This is our housing application. Please fill out all information to the best of your ability. Step 1 of 9 11% HousingWhich Housing Program Are You Applying ForFuller House for Women & ChildrenLighthouse for MenNew Start House for Men & WomenPersonal Information:Today's Date MM slash DD slash YYYY Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AgeDOB Month Day Year SS# (without dashes)Phone*Email* Emergency Contact Name First Last Emergency Contact's Phone NumberIndicator Code(s) PPW IUID Homeless Medicaid Adolescent Military Status Active Duty Veteran Reservist Not Affiliated Family CompositionMarital Status Single Married Divorced Widowed Number Of DependentsAre you currently pregnant Yes No Unknown Due Date MM slash DD slash YYYY Do you have Children? Yes No Age/Gender Will they be living with you?NoFull TimePart TimeVisiting Financial InformationCurrent Working Status Working Unemployed Injured Laid Off Full-time Student Part-time Student SSI Employer Job Title Hire Date MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Employers Name First Last Employer's Phone NumberOK to CallNoYesPicture of Work Schedule (if applicable)Max. file size: 450 MB.Last Date Worked MM slash DD slash YYYY Current Rate of PayDate of Last Paycheck MM slash DD slash YYYY Date of Next Payday MM slash DD slash YYYY Do you currently receive food stampsNoYesMedicaid RecipientNoYesPlease Note Any Physical Restrictions Housing InformationCurrently HomelessNoYesHousing Own Rent Sharing Room Hotel c&s House Living in car Monthly RentDue Date MM slash DD slash YYYY Are you up to date on your rentDoes Not ApplyYesNoDo you receive housing assistanceNoYesSource of Housing Assistance Notes Substance Use & Mental HealthAre you Actively UsingNoYesDate of Last Use MM slash DD slash YYYY Immediate Risk of UsingNoYesDo you believe that you need treatment servicesNoYesAre you willing to attend treatmentYesNoIn need of detoxNoYesDate of last SUD assessment MM slash DD slash YYYY Are you currently enrolled in treatmentNoYeTreatment Provider Level of Care 3.5 Inpatient 3.3 Inpatient 2.1 Intensive Outpatient 1.0 Outpatient RP Drug Court Participant Continuing Education Drug Court Participants Phase 1 Phase 2 Phase 3 Phase 4 Other Courts Behavioral Health Family Court Veterans Court CPS Primary drug of choice Secondary drug of choice Third drug of choice Fourth drug of choice Are you enrolled in mental health treatmentNoYesWhere Length of engagement Current MedicationsAdditional Notes Criminal HistoryDo you have a criminal historyNoYesType Felony Misdemeanor Date of last conviction MM slash DD slash YYYY List all charges Pending Court DateNoYesDate of Pending Court Appearance MM slash DD slash YYYY Are you required to register as a sex offenderNoYesPO / DOC Officer First Last PO / DOC Phone NumberNo Contact order(s) Yes No Need ExplainAdditional Notes TransportationDrivers License Status Active Suspended Expired Out of State Never Licensed Out of State License Do you have a vehicleNoYesDo you have valid insuranceNoYesPrimary method of transportation PV Public Transportation Rides from others Other Explain EducationHighest Level of Education Are you currently enrolled in schoolNoYesSchools Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Program Name Time Remaining / End Date Current GPA Do you have outstanding student loansNoYesAmountAre you interested in returning to schoolUndecidedYesNoAdditional Notes Written AnswersWhy do you feel that our program would be a good fit for you?Personal Challenges and GoalsDomestic ViolenceCheck All That Apply To You Victim of Domestic Violence Convicted of Domestic Violence Fleeing Domestic Violence Currently Subject to NCO Prohibited CrimesHave you committed or been charged of Rape Sexual Assault Abuse of a Minor Elder Abuse Arson Download QR
