Consistent Care Supportive Housing (CCSH)
PROGRAM APPLICATION
Welcome to Consistent Care Supportive Housing (CCSH). This application is designed to help us understand your background, needs, and goals so we can determine whether our program is a good fit for you. CCSH is a structured, recovery-focused living environment that supports individuals in building stability, accountability, and long-term success.
The information you provide will be used to assess eligibility, ensure the safety and well-being of all residents, and coordinate appropriate services and supports. Some questions may feel personal; however, each section plays an important role in creating a safe, respectful, and supportive community. All information will be kept confidential and shared only as necessary for program operations, in accordance with applicable privacy guidelines.
We ask that you complete this application honestly and thoroughly. Providing accurate information helps us support you more effectively and avoid delays in the intake process. Submitting an application does not guarantee acceptance, but it is the first step toward potential placement in the program.
If you have questions at any point, please reach out for assistance. We appreciate your interest in CCSH and your commitment to moving forward in your recovery journey.
Basic Identifying Information
This section collects your basic identifying and contact information to help us accurately process your application and communicate with you throughout the intake process. The information you provide will be kept confidential and used only for program-related purposes, including verifying identity, coordinating services, and ensuring we can reach you or an emergency contact if needed. Please ensure all details are complete and accurate.
*First Name:
Client first name
*Middle Name:
Client middle name
*Last Name:
Client last name
*Gender:
Client gender
*Birthdate:
Client birthdate
*Age:
Number field
*Social Security Number:
SSN
*Social Security Number (Confirm):
SSN
Phone Number:
Client phone
Email:
Client email
Address:
Client Address
City:
Client City
State:
Client State
ZIP Code:
Client Zip
Emergency Contact Name:
Text field
Relationships to Client:
Text field
Emergency Contact Phone Number:
Number field
Identification and Legal Status
This section gathers information about your identification and current legal status to ensure compliance with program requirements and any external obligations you may have. Providing accurate details helps us coordinate appropriately with legal authorities, when applicable, and determine eligibility for housing. All information will be handled confidentially and used only to support your placement and success within the program. Applicants also authorize Consistent Care to perform a criminal history check to ensure information provided below is accurate.
*ID Type:
Dropdown
State:
Client State
ID Number:
Text field
ID Expiration:
Date
*Have you ever been convicted or charged with a sex offense?
Dropdown
*Have you ever been convicted or charged with arson?
Dropdown
*Have ever been convicted or charged with kidnapping?
Dropdown
*Are you on parole?
Dropdown
*Are you participating in court-ordered treatment?
Dropdown
Do you have any pending charges?
Dropdown
If so, please explain:
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Probation/Parole Officer Name:
Text field
Officer Contact Number:
Number field
Court Requirements/Conditions:
Paragraph
Probation
Criminal History
Recovery and Substance Abuse History
This section asks about your recovery journey and substance use history to help us better understand your experiences, supports, and current stage of sobriety. The information you provide allows us to assess program fit, identify any additional support needs, and ensure a safe and recovery-focused environment for all residents. We recognize this is personal information, and it will be treated with respect and confidentiality. Please answer honestly so we can best support your success in the program.
TreatmentCenterHistory
*Client substances of choice
*Client kinds of meetings attended
*Are you currently enrolled in treatment (IOP, OP, etc)?
Dropdown
Treatment Provider Name:
Text field
Contact Information:
Text field
*Are you current involved with a 12-step program?
Dropdown
*Do you have a sponsor?
Dropdown
*Have you ever overdosed?
Dropdown
If yes, then please explain the cirumstances:
Paragraph
Medical and Mental Health
This section gathers information about your medical and mental health history to help us understand any current conditions, medications, or supports that may impact your stay. This allows us to promote a safe living environment, coordinate care when appropriate, and ensure the program is a good fit for your needs. Some questions are sensitive, but all information will be kept confidential and used only to support your health, safety, and overall success in the program.
*Do you participate in MAT?
Dropdown
Medication
Client health problems
If you select 'Other', please explain:
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Client diagnosis
Do you have a history of psychiatric hospitalization?
*Dropdown
If so, please explain:
Paragraph
Housing and Program Fit
This section helps us understand your housing needs and overall fit for the program. We ask about your reasons for seeking sober living, your goals, and your readiness to participate in a structured, recovery-focused environment. Your responses help us determine whether Consistent Care Supportive Housing (CCSH) aligns with your needs and whether we can provide the level of support necessary for your success. Please answer thoughtfully and honestly so we can make the best possible placement decision.
*What are your reasons for seeking sober living?
Paragraph
*What is your desired move-in date?
Date
Length of Stay Requested:
Text field
SoberLivingHistory
Personal Goals & Program Engagement
This section focuses on your personal goals and level of engagement in the program. We want to understand what you hope to achieve during your time in housing, including your recovery, employment, and life goals. Your responses help us tailor support, track progress, and ensure you are prepared to actively participate in a structured, goal-oriented environment. Being clear and honest about your goals allows us to better support your long-term stability and success.
*Short-Term Goals (30–90 days)
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*Long-Term Goals
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*Employment/Education Goals
Paragraph
*Recovery Goals
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*What support do you feel you need to succeed?
Paragraph
Agreement & Signatures
This section outlines the agreements and acknowledgments required for participation in Consistent Care Supportive Housing (CCSH). By reviewing and signing, you confirm that you understand and agree to follow program rules, financial responsibilities, and expectations for behavior and participation. These agreements are essential to maintaining a safe, respectful, and structured living environment for all residents. Please read each item carefully before signing, as your signature indicates your commitment to comply with all program requirements.
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
PLEASE INTIAL AND SIGN BELOW:
Random drug/alcohol testing
Initials Text field
Curfew compliance
Initials Text field
Visitor restrictions
Initials Text field
Zero tolerance policies
Initials Text field
I have read and agree to the Key Expectations and Requirements
Signature