NEXT CHANCE INC

APPLICATION FOR SOBER HOUSING

 
If you are interested in applying for residency, please complete this intake form and someone will reach out to you.

Resident Information:

First name: Client first name

Last name: Client last name

Preferred nickname: Client nickname

Gender: Client gender

Preferred Pronouns: Client pronoun

Race/Ethnicity: Client raceClient ethnicity

Phone number: Client phone

Email address: Client email

Date of Birth: Client birthdate

Home City/State: Client CityClient State

Emergency Contact: Contact

Next Chance Inc. consists of two locations: The Shore House (Pocasset) and The Farm House (Forestdale). Which location are you applying to today?

Client facility

Are you open to either location, or interested in any other affiliated housing?

Checkboxes

What is your current sobriety date?
(Enter an estimated date for your last relapse if this is not your first attempt)

RecoveryHistory

What is your substance(s) of choice?

Client substances of choice

Have you experienced dependency or over use of psychedelic substances such as psilocybin mushrooms, acid, cannabis sativa, ketamine, DMT, Mescaline, peyote, ayahuasca, or 2C-B?

Checkboxes

Have you ever experienced dependency or over use of inhalants, such as computer/electronic duster or paint thinners/sprays?

Checkboxes

What medications are your currently taking? 
To the best of your ability, please list the names of all your current medications:

Paragraph

Do you have any co-occuring conditions? (Please choose all that apply)

Client diagnosis

Do you have a history of self-harm, self-injury, and/or cutting? 

Checkboxes

Have you ever been diagnosed with an eating disorder, or fear you may have one?

Checkboxes

Do you have any health issues/concerns we should be made aware of?

Client health problems

Do you have any allergies we should be made aware of?

Client allergies

Are you curently pregnant? 

Checkboxes

 If there is anything else you feel necessary to share, please do so here:

Paragraph

Substance Use Treatment Information:

Please share most recent treatment history including detoxification, residential, PHP, IOP, OP:

Text field

If you are active in a treatment program, please provide your case manger's information so we can reach you:

Case manager name:Text field

Case manager phone number: Text field

Case manager email: Text field

Potential Discharge date: Text field

 

Financial Information:

Do you collect either Social Security or Disability income?

Checkboxes

Are you currently on leave from your job and collect FMLA, or currently collect unemployment?

Checkboxes

Do you collect food stamps/SNAP benefits?

Checkboxes

Do you collect additional cash assistance or supplemental income? 

Checkboxes

Do you have family who can help support you financially?

Checkboxes

Are you in need of a financial scholarship in order to secure sober housing today?

Checkboxes

If yes, please tell us why you need a scholarship, and how a scholarship would help you become more successful:

Paragraph

As part of your programming at Next Chance, we use a simple phone application for checking into curfew, as well as local fellowship meetings and additional house activities. 

Do you have a working cell phone? 

Checkboxes

If no, explain:

Paragraph

Are you reluctant to use a phone application, or do you fear you may have difficulty navigating the technology? 

Checkboxes

Additional Information: 

Are you currently employed?

Checkboxes

Do you have any children?

Checkboxes

If yes, please list their names, ages, and living situation:

Paragraph

Do you have any DCF involvement? 

Checkboxes

Are you currently on Probation or Parole? 

Checkboxes

If yes, please explain your charges:

Paragraph

 

Interests

Do you have any interest in alternative wellness modalities such as yoga, meditation, and acupuncture?

Checkboxes

Do you have an interest in caring for animals and/or learning to care for them?

Checkboxes

Do you have any experience in homesteading, gardening, or tending to livestock? (If yes, explain)

Paragraph

Do you have any other interests you would like to share with us? (Ex. sports, music, etc)

Paragraph

Please press submit when you have completed this form. Someone will reach out to you shortly to complete a phone interview.

Phone interviews can also be arranged by text to 774-258-8573 or by email to Lana@nextchanceinc.org