Housing Support (GRH) Residential Application

FreedomWorks Supportive Housing promotes safety, security, and sobriety for each of our residents.  Our living environment provides residents adequate structure and accountability, along with enough freedom to manage their own lives while complying with the expectations of the FreedomWorks culture. 

FreedomWorks staff will review the application materials. At the end of the review process, FreedomWorks staff will promptly send you a letter to advise you of their decision.

 

Date of Application Date               Desired move-in date Date

 

Personal Information

Applicant  Client first name Client middle name  Client last name     

SS# Text field    Date of Birth Client birthdate  

Email Client email  Phone Client phone  Address Client Address

Do you own your own vehicle? Dropdown  

Year/Make/Model Text field  License Plate Number Text field

Do you have a valid drivers license? Dropdown  State Text field  

License number Text field

Who referred you to us?  Client referred by

 
Criminal History

Have you ever been incarcerated?  Dropdown   When/How long?Text field   

ReasonText field

Are you currently on probation/parole? Dropdown   

Who is your P.O.? Text field  

Are you on Intensive Supervised Release? Dropdown   

Have you ever been convicted of a sex offense? Dropdown

Do you have any current or pending charges? Dropdown   If yes, please explain Text field

 

Medical History

Please list any medication you are taking 

Paragraph

 

Your Recovery

Addiction type(s):    Checkboxes   Checkboxes   Checkboxes  CheckboxesText field

What is your substance(s) of choice? Client substances of choice

Date of last use: Date   What was used? Text field

Past Treatment you have been in:

Name: Text field   Did you successfully complete the program? Dropdown

Name: Text field   Did you successfully complete the program? Dropdown

 

Have you lived in a Sober House before? Dropdown  When/ how long? Text field

Name: Text field  Location: Text field  Why did you leave? Text field

 

Government Assistance

Do you currently have General Assistance (GA)? Dropdown

Do you currently receive Social Security, Disability, or Unemployment? Dropdown

Do you currently have Housing Support/GRH?: Dropdown   

If yes, what is your case number?:Text field

Have you ever received Housing Support/GRH?: Dropdown

If yes, when?:Text field

 

 
Emergency Contact

Name:Text field  Relationship:Text field  Phone:Text field

 

References

Name:Text field   Relationship:Text field   Phone:Text field

Name:Text field   Relationship:Text field   Phone:Text field

 

Authorizations

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.

I authorize FreedomWorks staff to contact my counselors, caseworker, parole offices, and any other supportive team member for additional information if needed.

    Applicant SignatureSignature Date: Date

 

Release of Information Authorization

Applicant's Full name:  Client first name     Client middle name    Client last name                              

                  Date of Birth:Client birthdate   SSN:Text field

I authorize FreedomWorks staff the right to speak to individuals, referrals and/or agencies regarding my acceptance into the FreedomWorks Community. I also authorize FreedomWorks staff to review and/or to receive mental health, physical health and probation/parole records upon request.  I understand that:

1. My health information is protected by Federal Confidentially Rules (42 CFR Part 2; and/or HIPAA, 45 CFR) and state privacy laws, and disclosure is allowed only with my authorization except in limited circumstances as outlined in FreedomWorks policies. I also understand that I have the right to inspect and receive a copy of my treatment records that may be disclosed to others as provided under applicable state and federal laws.

2. I can revoke this authorization in writing at any time by providing a written notification to FreedomWorks, except to the extent that action has been taken in reliance on it.

3. Communications resulting from this authorization will reveal that I have received or have attempted to receive accommodations at FreedomWorks’ Sober Housing Recovery Community.

4. Federal confidentiality regulations prohibit disclosure of information.

5. While living in the FreedomWorks Sober Housing Recovery Community. I cannot revoke the authorization release of information.  I can, however, revoke this authorization upon leaving FreedomWorks.

Applicant Signature: Signature   Date:Date

 Office use only:

              FreedomWorks Staff signature:______________________      Date:_____________

 

___________________________________________________________________________________________________________________________

 

I chose to revoke this authorization

Applicant signature:________________________  Date:______________