Your Future Awaits Please choose one form to complete: Application - Short Form Application - Short Form Name * First Name Last Name Phone * (###) ### #### Email * Who referred you? How did you hear about us? Kindly put name of person/agency and phone number. * Gender? * Male Female Other Message This is a shared living house. Please let us know what services you are interested in and how we can help! Thank you! We will contact you shortly. Application - Long Form Application - Long Form Name * First Name Last Name Phone * (###) ### #### Email * Current Address? * Application date * MM DD YYYY Who referred you? How did you hear about us? Kindly put name of person/agency and phone number. * Who is the application for? * Myself Family Member A client (I am - Case worker, referral agency, social worker or sponsor) Gender? * Male Female Other Age? * Height? * Weight? * Are you pregnant? * Yes No N/A Are you aware that this is a shared living home? * Yes No Have you lived in shared housing before? * Yes No Current Living Situation? * Group home shared living Living with family Living by myself Living with roommates Living in a motel Homeless with no permanent place to live How long would you like to be a guest at our home? * 1 - 3 months 4 - 6 months 7 - 12 months 1 - 2 years Funding source? * Self Pay Voucher Social Security Insurance Social Security Disability Insurance Government or State Organization Non Profit Organization - Rent Assistance If you receive a voucher, what is the voucher's name? Write "N/A" if this doesn't apply. * Are you employed? * Yes No If you are employed, what are your hours/shift and what city & zip code do you work in? * If you are not, do you intend to apply for a job within 1 month of your arrival in Lo and Behold Housing? * Yes No If you don't intend on working or going to school, etc. explain why not and what you plan on doing with your daytime hours? * Criminal History * I Have A Felony I Have A Misdemeanor I Have No Criminal History If yes, please provide details of any criminal charges or convictions you have, including the nature of the charges and any associated legal outcomes. * Do you have a probation officer, etc? If so, what is their name and phone number and extension? * Funding Source Details : 1. What is the monthly income that you receive? * Funding Source Details : 2. What is the specific date that your payment is disbursed? * Funding Source Details : 3. Any additional Income Information ie. Part-time job? * Please disclose any existing medical/mental conditions or health concerns that we should be aware of. What have you been diagnosed with, if any? * Do you have any food or drug allergies? If yes, please elaborate. * Are you currently attending Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings? If yes, please specify which one(s). If no, do you need to find a meeting to attend? If this doesn’t apply, write N/A. * Are you currently taking any medications? * No Yes - Prescription Medication Yes - Over The Counter Medication If yes, please provide a list of the medications you are taking, including their names and dosages. * Are you currently taking any medications as part of your recovery treatment? If yes, please specify which one/s. * Do you have a sponsor or are you/will you be actively seeking one? (Please specify) If this doesn’t apply, write N/A * How long have you been in recovery? Please provide details about your recovery journey. * Are you involved in any other support groups or programs related to recovery? If this doesn’t apply, write N/A * Have you completed any rehabilitation or treatment programs? If yes, please provide details. If this doesn’t apply, write N/A * Are you coming from another group home? If yes, please specify which one and for how long you've been living there and the reason for leaving. * Do you have a history of relapse? If yes, please provide details and specify if you have a relapse prevention plan in place. * Do you have any specific needs or requirements related to your recovery journey that you would like us to be aware of? * Primary Mode of Transportation? * Public Transportation Personal Vehicle Do you smoke? * Yes No If yes, what do you smoke? * Do you agree to a drug test prior to your move-in date? * Yes No Do you agree to random drug tests? * Yes No We have house rules to govern the safety and harmony of the home? Would you abide by them? * Yes No Preferred Move In Date? * MM DD YYYY Any important details we should be aware of, not yet addressed? * Thank you! We will contact you shortly. Have a question? Contact us at:info@LoAndBeholdHousing.com281-588-0258
