Application for Thrive House Living Program
Welcome to the Thrive House, Inc. application wizard.
Please answer the following questions completely and truthfully. Once received we will review your application and contact you.
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 gender?
Radio buttons
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status
Do you have children? If so, what are their ages?
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Income
Tell us about your current situation and future plans.
Are you working or looking for work?
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If yes, please list your current employer or type of work you are looking to for.
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Do you plan on attending school or training and if so, what type?
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What other means of support do you have? (Check all that apply)
Checkboxes
Medical History
Tell us about your medical history.
Do you or have you ever struggled with substance abuse?
Radio buttons
Are you currently in recovery?
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Are you currently participating in any treatement or recovery program? If so, what program?
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When was your last relapse date?
Recovery history 1 relapse date
What is 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 health problems? Add multiple by clicking in the box and selecting different options
Client health problems
List any prescription medications you are currently taking, why you are taking them and your prescribing doctor.
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List any health insurance coverage you have currently.
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Criminal Background
Please list any prior or pending charges.
Please Include charge, county and status.
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DOC Number
Text field
List the name of your probation or parole office and department location (if applicable).
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Living Arrangements
Tell us about your living arrangement prior to moving into this facility.
Describe your current living arrangements. Please include if you are currently in a treatment center or incarcerated.
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Have you previously lived in a recovery residence or sober living home?
Radio buttons
If yes, please provide the following information:
SoberLivingHistory
Are you currently or have you ever experienced homelessness or living in a transitional home or facility? Please explain.
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List times you have lost housing and why.
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Client Referral Source
How did you hear about us?
Client Referred By
Other Information
What date would you like to enter the Thrive House Living Program?
Date
What is the estimated length of stay?
Client estimated length of stay
Are you working with any other organiztion or case managers that are helping with resources? Please Explain.
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What are your goals and plans?
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What other information should we know about you to assist you?
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