Lasko Refuge Application

General Information (required)

First Name
Client first name

Last Name
Client last name

Date of Birth
Client birthdate

Phone Number
Client phone

Drivers License Number
Text field

Make/Model of Car
Text field


Contact Information (required)

Current Address
Client Address

Client City Client State Client Zip


Recovery Information (required)

Last Time You Used

Probation/Parole Officer Name and Number

Are you a registered sex offender?


Payment Information (required)

If your rent is being paid by an Agency, please list them below. If you are paying yourself, please write "self".

Agency Name & Contact Information
Text field


Employment Information (required)


Emergency Contact (required)


House Information

Which house are you interested in?
Client facility

Date you would like to move in?