Harbor Care Recovery Housing Application
(Incomplete applications will not be processed until completed in full)
DATE OF APPLICATION: Date
Applicant’s Name:Client first nameClient middle nameClient last name
DOB: Date
Recovery Date:Date
Current Address: Client Address
Phone Number: Client phone
Email Address: Client email
WHO REFERRED YOU: Client Referred By
EMERGENCY CONTACT:
1. Contact
2. Contact
Current Sponsor:
Name: Client sponsor
The weekly rent for residents is $185 per week and you MUST show proof of income, or funding from another source such as doorways, as part of the eligibility process and prior to move in
Income Sources
(Please include all sources of income)
1. SSI/SSDI: Dropdown
Amount:Number field
Frequency:Dropdown
2. Employment: Dropdown
Amount: Number field
Frequency:Dropdown
3. Other Income(Doorways Funding):Dropdown
Source: Text field
Amount: Number field
Frequency:Dropdown
4. Other 3rd Party:Dropdown
Source: Text field
Amount:Number field
Frequency:Dropdown
Substance Use/Recovery History
What is your SOC (substance of choice):Client substances of choice
when was your last use:Date
What other substances have you used:Client substances of choice
when was your last use:Date
Are you able to pass a UA/drug screen? Pick one: Dropdown
Have you ever had any periods of sobriety? Choose One:RecoveryHistory
If yes, please list dates:
1. Date to Date
2. Date to Date
3. Date to Date
Have you experienced overdoses, Choose One: Dropdown
if yes how many times? Checkboxes
Were you narcanned and/or sent to the hospital? Choose One: Checkboxes
Have you ever overdosed in a recovery house? Choose One: Checkboxes
Are you on MAT (suboxone, methadone, etc.)? Checkboxes
If yes what method of MAT are you on currently: Text field
Who do you see for MAT services: Text field
Are you currently in treatment for your substance use: Checkboxes
If yes where: Text field
What is your Graduation Date:Date
Is an outpatient program such as HIOP/PHP recommended for aftercare? Checkboxes
SUD Treatment History:
1. TreatmentCenterHistory
Sober/Recovery House History
1. Have you ever lived in sober living before? Checkboxes
2. If yes, please list previous sober living/recovery housing residencies:
3. SoberLivingHistory
5. Have you ever been asked to leave a sober/recovery house? Dropdown
If Yes, Why? Text field
Medical and Mental Health History:
Do you have any medical conditions? If so please list:
1.Client health problems
Have you been diagnosed with any mental health disorders? If so please list:
1. Client diagnosis
Are you on any medications? Please list:
1. Medication Name: Medication
Dosage: Text field
Are you currently experiencing any of the following? (Choose One)
1. Suicidal ideation: Checkboxes
2. Homicidal ideation: Checkboxes
3. Self-Harm: Checkboxes
4. Delusions/Paranoia: Checkboxes
Where do you currently receive your medical and mental health care?
1. Medical Provider: Text field
Practice Name: Text field
Phone Number: Number field
2. Behavioral Health Provider: Therapist/Clinician
Legal History
Do you have any current legal issues pending? Please list:
1. Criminal History
_______________________________________________________
2. Criminal History
________________________________________________________
3. Criminal History
_________________________________________________________
Do you have any active warrants? (Choose One): Checkboxes
__________________________________________________________
Are you currently on probation or parole? (Choose One): Checkboxes
Probation: Probation
We will complete a criminal background check to confirm criminal history
Have you ever been charged and/or convicted of any of the following?
1. Sex offenses? Checkboxes
Date of offence:Date
2. Arson: Checkboxes
Date of offence: Date
3. Violent crime with weapon:Checkboxes
Date of offence:Date
4. Hate crime: Checkboxes
Date of offence:Date
5. Domestic assault: Checkboxes
Date of offence: Date
6. In what State did any of the above take place? Text field
7. If you answered yes to any of the above charges/convictions, please explain: Text field
Safety
1. Are you able to safely and independently climb stairs? Checkboxes
2. Are able to independently manage daily living tasks (shower, cook, etc)? Checkboxes
3. Are you able to walk to mutual aid meetings in the community? Checkboxes
4. Are you able to fully participate in house activities and expectations such as house meeting, social activities, chores, etc? Checkboxes
5. Are you willing to get a sponsor or recovery mentor? Checkboxes
6. Do you agree that you may not stay in the house if you return to use? Checkboxes
7. If you answered no to any of the above questions, please explain:Text field
Recovery Goals
1. What are your recovery goals for while you are in recovery housing?
- Goal #1: Text field
- Goal #2: Text field
- Goal #3: Text field
2. What can we do to help you achieve those goals while in recovery housing? Text field