Personal Information

What is your email address?

Client email

First Name:

Client first name

Last name:

Client last name

How did you hear about our Program?

Text field

SSN #

SSN

What is your gender?

Client gender

Date of Birth

Client birthdate

Requested Move in Date?

Date

DOC #

Number field

If you are on DOC Supervision, CCO Name

Text field

CCO Phone Number

Client phone

CCO Email Address

Text field

WDL #

Number field

Phone Number

Client phone

What is your race/ethnicity?

Client raceClient ethnicity

Are you a US Veteran?

Client veteran status

Marital Status

Client marital status

Children Yes or No and how many

 CheckboxesNumber field

Current Living Status

LivingArrangementHistory

Justice Involvment

Latest Criminal Charges?

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Are you a Registered Sex Offender?

Checkboxes

Have you been convicted of Arson?

Checkboxes

Have you been convicted of any Violent Offenses including DV?

Checkboxes

If answered yes, please list Charges, Dates and a Brief Explantion.

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If you are currently incarcerated, have you been written up for any violations during your current incarceration?

Checkboxes

Please list violation with brief explanation.

Paragraph

Pending Charges or Warrants?

Checkboxes

Are you on DOSA?

Checkboxes

Employment/School

Are you currently employed?

Checkboxes

If yes, Where?

EmploymentHistory

Are you able to begin work within two weeks of enetering our program?

Checkboxes

Do you plan on obtaining additional Training or Education?

Checkboxes

Payment Source

Will you be paying your program fee (Self Pay)?

Checkboxes

Have you been approved for DOC Voucher?

Checkboxes

If yes how long?

Dropdown

Have you been approved for HEN Funding?

Checkboxes

Have you been approved for SSI Funding?

Checkboxes

Are you relying on another program to pay your Fee's?

Checkboxes

If Yes, please provide the program, a contact person and thier phone number.

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If you have an agency assisting you in your housing search, please provide the name of the agency, contact person, Email address and their phone number.

Paragraph

Have you lived in Transitional Housing before?

Checkboxes

If yes, What organization?

Text field

How was your experience?

Text field

Medical History

Do you require medical treatment?

Checkboxes

Do you require mental health treatment?

Checkboxes

Are you currently receiving mental health treatment?

Checkboxes

If yes, Please provide physician name and phone number.

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Do you require daily assistance from a provider?

Checkboxes

Have you been prescribed any medication?

Checkboxes

Medication

Are you taking your medication as directed?

Checkboxes

Current recovery Program

Are you enrolled into MAT program?

Checkboxes

If yes, Please provide Physician name, Email and phone number.

Paragraph

Please list all prescribed medications you are currently taking and dosage.

Medication

Your Drug of Choice?

Client substances of choice

How many AA/NA meetings do you attend per week?

Number field

AA/NA Birthday- Last used Date?

Date

Current Step?

Client step

Sponsors Name?

Client sponsor

Do you plan on attending 90/90 (90 meetings in 90 day)?

Checkboxes

With limited beds available, what makes you the best canidate for this house?

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Contact Information

Emergency contact Name:

Contact

Relation:

Family Members

Address:

Client Address

Phone Number:

Client phone

Email Address:

Client email

May we release information about you to them?

Checkboxes

Your Preffered House?

Checkboxes  Hutton House - 1927 W 8th Ave. Spokane WA 99204

Checkboxes  Boone House - 1819 W. Boone Ave Spokane WA 99201

Checkboxes  Mt. Vernon House - 2809 E. 37th Ave. Spokane WA 99213

Checkboxes  Regal Home - 2811 E. 37th Ave. Spokane WA 99213  

Checkboxes  Univeristy House - 12505 E. 31st Spokane WA 99206 

 

By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.

 

All of the information provided above is true to the best of my knowledge and is not misleading in any way. I understand that inaccurate or misleading information on the application is a cause for immediate removal from our program at any time.

Signature

Date