Evergreen House Foundation Application

 

Evergreen Shared Housing Application 

Welcome to your metamorphosis.

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To better assist you please answer as many question in as much detail.

Have you read Evergreen's House Rules / Residential Agreement? Dropdown

If you have not read the House Rules, please go back to EvergreenSharedHousing.org in About section and read the document. Also available here if you click House Rules & Residential Agreement

I have read the House Rules and I am ready to continue with the application: Dropdown

Click next to begin!

General

Tell us about yourself
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Social Security Number? SSN
Driver's License Number? Text field
Are you a veteran?
Client veteran status
Do you have any children?Dropdown
What are your transportation means?Dropdown 
 

Contact Information

How can we reach you?
What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip
Consent to Background Check: 
Dropdown
What is your legal status:
Dropdown
 

Contacts

Give us at least 2 people that we can reach out to in case of an emergency.

Contact

Contact

                      
 

Insurance

Enter your insurance provider(s).

Insurances

 

Medical History

Tell us about your medical history.
When was the last date you used substance/s?
Recovery history 1 relapse date
Have you received substance abuse treatment?
Dropdown
What was your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any physical health problems/diagnosis? Add multiple by clicking in the box and selecting different options
Client health problems
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Dropdown
What allergies do you have? No allergies? Move on to the next question.
Client allergies

Have you had any of the following tests?

Medical Tests
 

Medications

List the medications you are currently prescribed.
Medication
Client medical notes

Treatment Centers

Tell us about any treatment centers you've been admitted into.
TreatmentCenterHistory

Client Referral Source

 
Who referred you to us?
Dropdown

Occupancy

 
Where are you currently residing? 
Text field
Where are you looking to stay at?
Client facility
What date do you wish to move in on?
Date
What is the estimated length of stay?
Client estimated length of stay
Are you aware of the Finacial Policy stated in the House Rules and a payment of $1130 required at the time of move in? 
Dropdown

Transitional Living History

Tell us about transitional livings (if any)
SoberLivingHistory

Employment

Tell us about your employment status.
List your current employment and employment history in the recent three years.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory
 What other means of finacial support do you have?
Dropdown

Living Arrangement

Tell us about your living arrangement history
LivingArrangementHistory
 

What should we know about you to better assist you?

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