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Welcome to the Homes With Heart Housing Application

Click next to begin!

 

 

General

Tell us about yourself

First Name:
Client first name
Middle Name:
Client middle name
Last Name:
Client last name
Birthdate:
Client birthdate
Social Security Number:
SSN
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status

 

 

Contact Information

How can we reach you? 

Email address:
Client email

Cell phone number:
Client phone

Mailing Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

What is the best way to contact you?
Radio buttons

 

 

Emergency Contacts

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

Contact

 

 

Transportation

How will you get around?

 
Driver's License or State ID Number
Text field
State Issued 
Text field

Do you have a car? 
Radio buttons
Is it registered and insured? 
Radio buttons

If you do not have a car, what is your primary mode of transportation? 
Text field

 

 

Education and Employment

Tell us where you are working or going to school

 

 

Are you currently enrolled in school or do you plan to enroll?
Radio buttons

Highest level of education completed:
Text field

Any vocational skills, specialized training or certifications:
Paragraph

Current employer and position held:
Paragraph

 

 

Health Insurance

Enter your insurance provider(s)

Insurances

 

 

 

Program Information

Tell us about program fee payment and living in a shared housing environment 

 

 

How will you pay the program fee for living in our residence? 
Paragraph

Do you have any concerns about living in a shared housing situation (2 or 3 residents per room)?
Radio buttons
If Yes, please explain:
Paragraph

Why do you think you are a good fit for shared housing?
Paragraph

Are you able to perform household chores?
Radio buttons
If No, please explain:
Paragraph

 

 

Medication, Substance Use and Recovery

Tell us about your substance use history

Describe your current treatment program:
Paragraph

List all drugs/alcohol you have used addictively:
Paragraph

When was the date of your last use?
Date

Do you use tobacco?
Radio buttons

List any medical conditions, mental health conditions or allergies:
Paragraph

List any prescribed or over the counter medications you are currently taking:
Paragraph

Do you have any other recognized addictions or disorders (eating disorder, cutting, etc)Add multiple by clicking in the box and selecting different options
Client diagnosis

Are you following any Medically Assisted Treatments (MAT)?
Radio buttons
If Yes, please explain:
Paragraph

Do you have a sponsor, case manager, or anyone else supporting your recovery?
Radio buttons

 Have you had any of the following tests?
Medical Tests

 

 

Treatment Centers

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

TreatmentCenterHistory

 

 

Courts

Provide information if you are or have been justice involved

 

 

Are you currently on probation or parole?
Radio buttons
Note: If Yes, and you do move into our home, you will be required to complete a release of information so we can communicate with your probation or parole officer

Are you currently experiencing any legal problems or involved in any legal proceedings?
Radio buttons
If Yes, please explain:
Paragraph

Are you required to register as a sex offender?
Radio buttons

Have you been charged or convicted of arson or any other violent crime?
Radio buttons
If Yes, please explain:
Paragraph

 

 

Other

Tell us a little more about yourself

 

 

What are your hobbies or special interests?
Paragraph

What are your main goals at this time?
Paragraph

How did you hear about Homes With Heart Foundation?
Paragraph

What else would you like us to know about you or your current situation?
Paragraph

 

 

By submitting this form, I confirm that all information contained in this application is accurate and I consent for Homes With Heart Foundation to complete a background check.