PIVOT PAD HOMES
Housing Program Application
Operated by Sanguine Operations LLC • 208.410.8653 • pivotpadhomes.com
Welcome. We take every application seriously because we believe in your potential for a fresh start. Please fill this out
completely and honestly — leaving sections blank may result in a delay or denial. If something doesn't apply to you, write
N/A. This information is confidential and used solely to determine program fit and prepare for your success.
SECTION 1 — WHO YOU ARE
Full Legal Name Client first nameClient middle nameClient last name Date of Birth Client birthdate
Age Text field
Last 4 of SSN SSN Gender Client gender
Personal Phone # Client phone
Emergency Contact Text field Relationship Text field
Phone # Text field
SECTION 2 — SUPERVISION STATUS (Complete if applicable)
IDOC # (if applicable) Text field
Current Facility / Location Text field
Expected Release / Housing Date Text field
Case Manager / PO Full Name Text field
CM/PO Email Text field
CM/PO Phone # Text field
Have you had your parole hearing? Radio buttons
Current Status (check one):
Radio buttons
SECTION 3 — YOUR BACKGROUND
Most recent conviction(s):
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County of offense(s) Text field
Will you be on probation/parole upon release? Radio buttons
Are you required to register as a sex offender? Radio buttons
Is this application a backup plan for an interstate compact or ICE detainer? Radio buttons
Do you have any violent crimes or Disciplinary Offense Reports (DOR) for violence? Radio buttons
If yes to violent crimes or DORs — briefly describe the offense, the DOR category and date, any programming completed, and the
changes you've made since:
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Have you ever been discharged or removed from a transitional home for any reason? Radio buttons
If yes — which house, when, and what happened:
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Do you need housing that allows child visits or overnight stays? Radio buttons
If yes — provide details:
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SECTION 4 — HEALTH, EMPLOYMENT & SUPPORT
Do you have employment lined up for release? Radio buttons
Employer Name Text field
Employer Phone / Email Text field
Will you have a vehicle on site? Radio buttons
If yes — proof of valid DL, registration, and insurance will be required.
ID documents on hand or ordered (check all that apply):
Checkboxes
Have you served in the military? Radio buttons
If yes — are you enrolled at the VA? Radio buttons
Do you have medical or mental health support needs? Radio buttons
If yes — describe your needs and any current providers:
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Do you have any contagious or communicable diseases? Radio buttons
If yes — please describe:
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List all prescribed medications you currently take:
Medication
Are you planning to apply for SSI, SSDI, Medicare, or Medicaid? Radio buttons
If yes — provide reinstatement date and a brief 90-day financial support plan:
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SECTION 5 — ADDICTION HISTORY
Pivot Pad is a safe and sober living program. Honesty here is not a disqualifier — it helps us serve you better. We ask
because we care about your recovery, not to judge your past.
Do you struggle with addiction? Radio buttons
Substance(s) of previous use and date of last use:
| Substance |
Date of Last Use |
| Text field |
Text field |
| Text field |
Text field |
| Text field |
Text field |
| Text field |
Text field |
Were you under the influence of drugs or alcohol when your crime was committed? Radio buttons
SECTION 6 — FAITH & PREFERENCES
Do you prefer a faith-based housing program? Radio buttons
Pivot Pad is a Christ-centered program. Faith is not required to participate, but respect for its values is. If you have faith convictions or
preferences, share them here:
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Preferred district for housing (check one):
Checkboxes
Have you previously lived in transitional housing? Radio buttons
House Name & City (if yes) Text fieldText field
SECTION 7 — YOUR PERSONAL STATEMENT
This is your opportunity to speak for yourself. Tell us who you are, what you're committed to, and why Pivot Pad is the
right next step for you. We read every word. Be real with us.
Why do you want to be at Pivot Pad, and what are you committed to?
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What does accountability mean to you, and how do you plan to apply it here?
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SECTION 8 — CERTIFICATION & SIGNATURE
I certify that all information provided in this application is complete, true, and accurate to the best of my knowledge. I
understand that providing false or misleading information may result in denial of my application or immediate removal
from the program. I authorize Pivot Pad Homes / Sanguine Operations LLC to verify the information provided and to
exchange relevant information with IDOC, case managers, probation/parole officers, or other authorized parties as
needed to process this application and support my housing and reentry.
Print Full Name: Text field Date: Date
Signature:Signature
FOR OFFICE USE ONLY
Date Received: Date Reviewed By: Text field
Decision: Text field
Notes: Client notes
"For I know the plans I have for you," declares the Lord, "plans to prosper you and not to harm you, plans to give you
hope and a future."
— Jeremiah 29:11
Pivot Pad Homes • Operated by Sanguine Operations LLC • 208.410.8653 • pivotpadhomes.com • 2638 Fairway Dr, Coeur d'Alene, ID
83815