Applicant Information
Why do you need transitional housing?*
Explain your current situation*
Referral Source Information
If you’re coming from a Hospital, Prison, Jail, or Rehab, you must have the following when you arrive: (1) One month supply of medications; (2) If diagnosed with a mental illness, a follow-up appointment at a local mental health office; (3) No Narcotic Pain Medications or Controlled Substances (Lortabs, Xanax, Benzos, Suboxone, etc); (4) Approved Psych Meds are allowed.
Are you being referred?*
— Select — Yes No Don't Know
If referred, Name of Person Referring You
If referred, Name of Organization Referring You
Referring Organization/Person's Phone Number
Applicant Health Information
Applicant's Health Condition*
— Select — Excellent Good Fair Poor
Do you have a disabling condition?*
— Select — Yes No Don't Know
Do you have a mental illness?*
— Select — Yes No Don't Know
What insurance do you have?*
— Select — I don't have insurance Medicaid Medicare Veteran's Administration (VA) Medical Services Employer-Provided Health Insurance Health Insurance via COBRA Private Pay Health Insurance State Health Insurance for Adults
List Prescribed Medications
Answer "NA" if you aren’t prescribed any. List what they are prescribed for. No Narcotic Pain Medications or Controlled Substances (Lortabs, Xanax, Benzos, Suboxone, etc).
Court, Parole, Probation Status
If yes, what is your DOC#?
If yes, please explain.
Answer "NA" if you don’t have a criminal history.
Previous Residency Information
Where are you currently staying?*
— Select — Streets Emergency Shelter Hospital Psych Hospital Jail/Prison Hotel/Motel Rental (House, Apartment, Other) With Family With Friend Substance Abuse Facility/Rehab Other
Length of stay at prior residence?*
— Select — One week or less More than one week, but less than one month One to three months More than three months, but less than one year One year or longer
If yes, did you leave on good terms?
— Select — Yes No Don't Know I've never been a resident
