PROGRAM APPLICATION

Please complete the following Program Application to be considered for participation at The Nova Residence. Once you receive confirmation of acceptance and would like to reserve a bed, please ensure your first month’s program fee is received prior to move-in. Payments may be mailed or dropped off in person (by appointment only) and must be in the form of money-order or cashier’s check made payable to The Nova Residence Inc. For your convenience, you may also pay online via paypal.me/novaresidence . No checks will be accepted. (All payments are non-refundable).

 

Today’s Date: Date IDOC or LE # Client level/phase

 

Name: Client first name Client last name Gender: Client gender

 

Address: Client Address City:Client City

 

State: Client State Zip:Client Zip

Date of Birth: Client birthdate  Client race Client ethnicity

 

Email:Client email Phone: Client phone

Marital Status Client marital status  

Emergency Contact: Family Members

 

Sober Living History: SoberLivingHistory

Date Housing Needed:Text field

DO NOT LEAVE BLANK. Please give a real date of expected arrival and/or release.

If you are approved through BPA for housing, please list out-patient treatment provider information: 

 

Treatment Provider: TreatmentCenterHistory

 

Medical Notes: Client medical notes

Allergies: Client allergies

List any medications you are prescribed:

Medication

Substance Abuse History

 

Do you have a substance abuse problem? Checkboxes

 

If yes, what is your drug of choice? Client substances of choice

Will you attend treatment?  Checkboxes

 

Drug and Alcohol Use

 Date of last Use: RecoveryHistory

If you are a participant of The Nova Residence’s program, Inc. would you be willing to address any and ALL abuse issues and agree to maintain a drug and alcohol-free residence? Radio buttons

 Criminal History

 

Have you been convicted of a misdemeanor or felony? Checkboxes

 

Have you committed any sexual offenses? Checkboxes

Are you required to register as a sex offender? Checkboxes

Have you committed any violent offsenss? Checkboxes

Explanations: Paragraph

 Were you under the influence of drugs/alcohol when crime was committed? Checkboxes

IDOC Data Sensitivity Classification - L3 Restricted

 

Will you be on probation or parole while in housing? Checkboxes

 

Name of Idaho County you will be reporting to: Contact

Probation/Parole Officer Name, if known: Text field

IDOC Data Sensitivity Classification - L3 Restricted

 

Case Manager Contact Info: Text field

_________________________________________________________________________

IDOC Data Sensitivity Classification - L3 Restricted

 

I have completed this application to the best of my ability and answered all questions honestly. When I am accepted into the program at The Nova Residence, I agree to hold harmless The Nova Residence, Inc., corporate officers, property owners, independent service contractors, and all service providers from all claims, actions and liabilities. I authorize The Nova Residence, Inc. to exchange information as needed with any and all government or private parties and/or their representatives as it relates to the application process and program status while participating in The Nova Residence program. I understand and agree that all payments to The Nova Residence, Inc. are non-refundable. I have read both statements above, understand its contents, and voluntarily agree to its terms.

 

Print Name: Text field            

 

Signature: Signature

 

Date: Date

 

 

Thank you for submitting your Program Application. A response letter will be provided within 48 hours of receipt and will provide instructions for Move in Day if accepted.  We look forward to meeting you soon.