Consider the Lilies Foundation

Step 1: General Applicant Details
Full Name (First, Last)*: Client first nameClient last name
Date of Birth (MM/DD/YYYY)*: Client birthdate
Age: Number field
Email Address: Client email
Phone Number: Client phone
Agency / Organization You Work With (Required)*: Text field
Marital Status: Client marital status
Gender: Client gender
Race: Client race
Ethnicity: Client ethnicity
Are You a Veteran?: Client veteran status
Do You Have an ID Card?: Dropdown
Driver's License / State ID Number*: Text field (Type "None" if not available)
Do You Have an EBT Card?: Dropdown

Step 2: Income, Funding & Healthcare
Income / Funding Source
Dropdown

Working / Currently Employed
Dropdown
DOC Housing Voucher
Dropdown
Social Security Benefits (SSI)
Dropdown
Social Security Disability (SSDI)
Dropdown
Drug Court Housing Funding
Dropdown
HEN Program Funding
Dropdown
VASH Funding
Dropdown
Healthcare Coverage: Dropdown

Step 3: Background, History & Support Organizations
Have you lived in shared housing or recovery housing before?: Text field
Have you ever lost housing? (Required)*: Dropdown
Please describe your situation:Paragraph
Do you have any debt or Legal Financial Obligations (LFOs)? / Other: Text field
Incarceration or Arrest History / Pending Charges?*: Dropdown
DOC Number (if applicable): Text field

Charge	Status
Text field	Text field
Text field	Text field
Text field	Text field

Place of Employment (if working): Text field
Education Level: Text field
What organizations or case managers help you with resources?: Text field

Step 4: Goals, Plans & Work History
Work History Summary: Paragraph
Are you currently working or actively looking for work?: Text field
Do you plan on attending school or job training? (Specify type): Text field
What are your goals and plans?: Text field
Is there anything specific you want leadership to know about you?: Text field

Step 5: Emergency Contacts & Additional Info
Primary Emergency Contact:

Name: Text field | Relation: Text field
Address: Text field
Phone: Text field

Secondary Emergency Contact:

Name: Text field | Relation: Text field
Address: Text field
Phone: Text field
What is your immediate need upon entering housing? (e.g., clothing, dental care, help finding services): Text field
Do you have children, and what are their ages?: Text field
Counselor / Treatment Provider Name & Contact: Text field

Step 6: Required Acknowledgements & Electronic Signatures
UA Consent and Limited Authorization to Release UA Results (Required)
I consent to baseline, random, and return-from-overnight urinalysis (“UA”) testing required by Consider the Lilies Foundation as a condition of entry to, and continued residence in, housing. I authorize Consider the Lilies Foundation to use and disclose only UA information (date, completion/refusal status, and indicated substances) strictly to necessary staff, Drug Court staff, counselors/case managers, and DOC staff.
Initials to Confirm*: Initials Text field
Privacy & Confidentiality Acknowledgement (Required)
I acknowledge that Consider the Lilies Foundation protects participant privacy under applicable confidentiality rules and will not confirm or disclose my program participation to third parties without my specific written authorization, unless required by law.
Initials to Confirm*: Initials Text field
House Rules and Medication Policy Acknowledgement (Required)
I acknowledge that I have received, read, and understand the house rules and program requirements. I agree to disclose all lawfully prescribed medications during intake and comply with medication policies, curfews, conduct rules, and safety protocols. I understand that non-compliance may result in immediate discharge from housing.
Initials to Confirm*: Initials Text field
Electronic Signature Acknowledgement:

By entering my initials above, signing below, and submitting this form, I certify that all information I have provided is true, complete, and accurate to the best of my knowledge.

Applicant Signature / Printed Full Name*: Signature
Date Signed*: Date