Lasko Refuge Application

Today's Date: Date

Desired Move-In Date:
Date

Property Address:
Please select the house you are interested in
Client facility

 

Move-in date and house of interest are subject to availability. Please note that if desired property does not have availability, you may be asked if you're interested in another one of our Lasko Houses.

 

*indicated a required field

 

Checkboxes

 

General Information

Legal Name*: Client first name Client last name

Nickname/Preferred Name: Client nickname

Email (if applicable): Client email

Phone: Client phone

Date of Birth*: Client birthdate

Social Security #*: SSN

 

Drivers License Information

DL #: Text field

State: Text field

Expiration Date: Date

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Car Information

Make: Text field

Model: Text field

License Plate #: Text field

Checkboxes 

 

Current Address Information

Address: Client Address

Date you Moved in: Date

Current Landlord: Text field

 

Probation/Parole Officer Information

Name: Text field

Phone: Text field

Email: Text field

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Referral Information*

How did you hear about us? If you don't see an option, type it in and press enter to add!

Client Referred By

 

Demographic Information

Race*: Client race

Ethnicity*: Client ethnicity

Gender*: Client gender

Preferred Pronouns: Client pronoun

Veteran Status*: Client veteran status

Marital Status: Client marital status

Are you a Registered Sex Offender?*
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Recovery Information

Substance(s) of Choice*: Client substances of choice

Recovery History*

Please list all clean/sober and relapse dates within the last year to the best of your ability.

RecoveryHistory

 

Checkboxes 

 

Employment Information

Please include your currrent employer. If you are not currently employed or unable to work, please let us know if you would be interested in job search resources or the circumstances as to why you are unable to work.

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EmploymentHistory

 

Emergency Contact Information*

Contact

 

 

Payment Information

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Agency Information

Agency Name: Text field

Person of Contact: Text field

Phone: Text field

Email: Text field

 

 

 

Signature

 

 

Applicant Signature

Signature