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Recovery Housing Application
Recovery Housing Application
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* Indicates required question
Email
*
Your email
Today's date
*
MM
/
DD
/
YYYY
First Name
*
Your answer
Middle Name
*
Your answer
Last Name
*
Your answer
Age
*
Your answer
Social Security Number
*
Your answer
What is your Race?
*
White
Black or African American
Hispanic
Asian
Native American
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Male
Female
Have you ever applied to or lived at the Restoration of Hope Project?
*
Yes
No
How did you hear about our program?
*
Your answer
Who is your contact person while incarcerated (if applicable)? This will be an employee that works at the institution you are at. We will notify should we decide to schedule an interview/to notify if accepted or denied.
Your answer
Permanent Address (if applicable)
*
Your answer
Phone number
*
Your answer
Marital Status
*
Married
Divorced
Separated
Single/Never Married
Widowed
In a relationship
Do you have children?
*
Yes
No
How many children?
*
Your answer
What are the names of your children?
Your answer
Sobriety date
*
MM
/
DD
/
YYYY
Are you on a grant?
*
Yes
No
If you are on a Grant list the agency and the contact person
*
Your answer
Primary substance used
*
Alcohol
Heroin
Methamphetamine
LSD
Cocaine
Marijuana
Bath Salts
K2 or Synthetics
Prescription Pain Medications
Other:
Describe any periods you have been able to remain abstinent. What did you do to achieve/maintain this?
Your answer
Have you lived in a recovery house before?
*
Yes
No
Name? (if no write n/a)
*
Your answer
How long were you there? (If no write n/a)
*
Your answer
Why did you leave?
*
Completed Program
Decided to leave on your own
Dismissed from program
Relapse
N/A
Have you ever been to a substance use treatment program?
*
Yes
No
Name? (if yes)
Your answer
When? (if yes)
Your answer
Did you complete it?
Yes
No
Clear selection
On a scale of 1 to 10, how serious of a problem do you think you have with drugs and/or alcohol? (10 being a serious problem)
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1
2
3
4
5
6
7
8
9
10
On a scale of 1 to 10, how motivated are you to make changes in your life at this time? (10 being very motivated)
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1
2
3
4
5
6
7
8
9
10
Do you have a mental health diagnosis?
*
Yes
No
If you answered yes, list your diagnosis. Include when and by whom this diagnosis was made.
Your answer
Have you ever been hospitalized in a mental institution?
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Yes
No
Reason for hospitalization
Your answer
If yes, when?
Your answer
Have you ever heard voices (not drug-induced)?
*
Yes
No
Date of last incidents (if yes)
MM
/
DD
/
YYYY
Have you ever had visual hallucinations (not drug-induced)?
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Yes
No
Date of last incidents (if yes)
MM
/
DD
/
YYYY
Are you suicidal?
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Yes
No
Have you ever tried to commit suicide?
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Yes
No
If yes, the date of the last incident
MM
/
DD
/
YYYY
Have you ever been diagnosed with Bi-Polar Disorder?
*
Yes
No
Have you ever been diagnosed with a learning disability?
*
Yes
No
If yes, which one?
Your answer
Have you ever been diagnosed with Autism?
*
Yes
No
Are you prescribed medications for a mental health disorder?
*
Yes
No
List all psychiatric medications prescribed
Your answer
Are you currently incarcerated?
*
Yes
No
If yes, the name of the institution and the name of your Institutional Probation Officer (if no answer n/a)
*
Your answer
DOC # (if applicable)
Your answer
Scheduled release date
Your answer
Do you have any pending charges or court dates?
*
Yes
No
Are you currently on probation?
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Yes
No
If yes, the name of your probation officer (in unknown or no write n/a)
*
Your answer
List all prior convictions
Your answer
Have you ever committed/been charged with arson?
*
Yes
No
Have you ever been charged with cruelty to animals?
*
Yes
No
Have you ever been charged/convicted of Endangerment to a child?
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Yes
No
Have you ever been charged/convicted of a violent crime?
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Yes
No
Have you ever committed/been charged with a sexual crime?
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Yes
No
Do you have the funds to cover the $350.00 entrance fee?
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Yes
No
Do you receive any ongoing financial reimbursement for any reason? (Such as SSI, Disability, Medicaid, Trust Fund, etc.)
*
Yes
No
Check which apply
*
I have a valid driver's license
I have my social security card
I have my a state ID
Birth Certificate
None
Required
Do you currently have a job?
*
Yes
No
Name of the company
Your answer
How long have you been employed?
Your answer
Describe employment history
Your answer
Do you have any existing barriers to obtaining employment?
*
Yes
No
Please describe employment barriers (if applicable)
Your answer
Do you have your own vehicle?
*
Yes
No
Are you court-ordered to pay child support?
*
Yes
No
Are you a high school graduate?
*
Yes
No
If yes where did you graduate from? (if no write last grade completed)
*
Your answer
Do you have your G.E.D.?
*
Yes
No
List any medical issues
Your answer
Do you have a primary care physician?
Yes
No
Clear selection
Do you have dental problems?
Yes
No
Clear selection
Do you have a history of seizures?
*
Yes
No
TB
*
Yes
No
Diabetes
*
Yes
No
Hepatitis
*
Yes
No
AIDS/HIV
*
Yes
No
Are you currently on medications for a physical health condition?
*
Yes
No
If yes, list medications
Your answer
Send me a copy of my responses.
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