Shalom Home Foundation Application
Personal Information
Legal Name:
Client first name
Client middle name
Client last name
If you prefer to go by a nickname, what is it?
Client nickname
Have you ever been know by an alternate name or alias?
Radio buttons
If you answered "Yes" to the previous question, what is your alternate name? Text field
Email: Client email
Phone Number:Client phone
Is this a Cell Phone?
Radio buttons
Agency Affiliation:Text field
Birth Date: Client birthdate
Race: Client race
Are you a Veteran? Client veteran status
I, applicant, consent to be contacted by the Shalom Home Foundation via SMS, email or phone using the information provided above for the purposes of reviewing my application.
Radio buttons
Do I consent to a background check? Note: Shalom Home Foundation does not accept anyone with a sexual crime, violent crime or arson conviction.
Radio buttons
Are you fleeing a domestic violence situation?
Radio buttons
Do you have concerns sharing a room (all rooms are shared)?
Radio buttons
Are you able to perform household chores? (If yes, then you are agreeing that you can do chores such as wash dishes, sweep floors, cut the grass, make your bed, clean kitchen, taking out the trash, water the grass, loading dishwasher, etc.)
Radio buttons
How long do you plan to stay with us?
Text field
Current Living Situation
We understand that everyone has a unique journey. In order to better understand your transition to our program, it is helpful to understand your current living situation.
If you don't remember everything, it's ok. Just fill out to the best of your ability.
Please list your living situation over the past 5 years?
LivingArrangementHistory
What is your current address?
Client Address
Do you plan on returning to your current living situation?
Radio buttons
Income and Employment
If you don't remember everything, it's ok. Just fill out to the best of your ability.
How will the program fees be paid?
Checkboxes
If you selected "Other", please list the person or organization that will be paying your fees: Text field
The fee to move into a Shalom Home is $150 One-Time Administration Fee + $200 First Week Program Fee = $350 Total Move-In Fee.
Are you able to pay the initial Move-In Fee of $350?
Radio buttons
Are you currently working?
Dropdown
Please list your employment history for the last 3 years (just do your best with dates):
EmploymentHistory
Are you currently looking for work?
Radio buttons
Do you need help finding employment?
Radio buttons
Do you collect Social Security?
Radio buttons
Are you currently attending school?
Dropdown
Please tell us about any other income here:
Paragraph
Healthcare and Medical Information
If you don't remember everything, it's ok. Just fill out to the best of your ability.
Do you have health insurance?
Radio buttons
If yes, what type of insurance do you have? (for example; Medicade or Medicare)
Insurances
Have you ever been diagnosed with any mental health issues?
Radio buttons
If you answered yes, what was your diagnosis?
Text field
Please list all medications being used:Medication
Please list any health problems?
Client health problems
If you are currently seeing a therapist, please list the following:
Therapist/Clinician
Sobriety History
If you don't remember everything, it's ok. Just fill out to the best of your ability.
Have you ever lived in sober living house?
Radio buttons
If yes, please list your sober living history:
SoberLivingHistory
To help us understand your recovery journey, please list sobriety dates and relapse dates? (If you don't know the exact dates, just estimate the approximate times)
RecoveryHistory
Do you have a sponsor?
Client sponsor
You be required to attend a minimum of 5 meetings a week. What recovery meetings are you currently attending?
Client kinds of meetings attended
Please list any treatment center history:
TreatmentCenterHistory
If, in the future, I relapse, I would like to go to (Please let us know a family member, friend that you would like us to call):
Text field
What is their phone number?
Text field
Incarceration and Arrests
Do you have any charges pending or outstanding warrants?
Radio buttons
If yes, what are the charges for? Paragraph
Please list any probation(s)?
Probation
Have you ever been convicted as a sex offender?
Radio buttons
Have you ever been charged with a violent crime?
Radio buttons
Have you ever been convicted of committing arson?
Radio buttons
Final Questions
If you are approved to join the Shalom Home Foundation program, when would you like to move in?
Date
If you are approved for the Shalom Home Foundation program, how long do you plan to stay with us?
Text field
What organizations or case managers are currently providing help or resourses to you?
Paragraph
What resources and/or help are you currently seeking?
Paragraph
What are your goals and plans for the future?
Paragraph
When you are done answering all of the questions on this form, please hit the "submit form" button. After reveiwing your completed application, we will get back to you as soon as we can. Thank you for your submitted application to the Shalom Home Foundation!