Application for Residency

Application for Residency

Your submission of this application in no way commits Life Changes, Inc. to accepting you into the program, nor does it commit you to enter the program. If you do not answer every question of this form, your application WILL NOT BE PROCESSED. If a question does not apply to your situation, enter N/A. Be advised, if you are currently residing in a Nevada Department of Corrections facility filling out this online application will delay the process. You MUST contact your caseworker or Pre-Release specialist for an application for reentry. Please visit our reentry fact page at https://www.lifechangesinc.solutions/reentry.
General Information
Status
Interview Notes
Today's Date

Month Day Year
Date
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Contact Phone Number
Contact Email
example@example.com
I consent to be contacted by Life Changes, Inc. via SMS, email or phone using the information I provided for the purpose of discussing my application. *

Yes No
Gender *

Male Female
Who referred you to Life Changes? *
Ethnicity *

American Indian or Alaskan Native Asian Black or African American Hispanic or Latino Hawaiian or Other Pacific Islander Caucasian Other Choose Not to Disclose
Describe your current living situation *

I am living in my own apartment/home I am living with family I am currently incarcerated I am currently living in a program I am currently homeless I am currently living in an unsafe environment
Are you a veteran? *

Yes No
Substance Abuse
What are your drug(s) of choice? (Including alcohol)
Are you currently participating in or anticipate entering any drug replacement program? (Like methadone, suboxone, etc) *

Yes No
Are you currently in an addictions/alcohol treatment program? *

Yes No
Have you ever participated in an addictions/alcohol treatment program? (Such as inpatient hospital detox or residential programs, outpatient treatment centers and sober living homes) *

Yes No
What 12-step or spiritual based programs do you attend? (Choose all that apply) *

None Narcotics Anonymous Alcoholics Anonymous Gamblers Anonymous AlAnon Celebrate Recovery SMART Recovery Church/Spiritual Services
What is your Clean/Sober Date? *

Month Day Year
Date
Are you will to attend self-help and spiritual groups and meetings while at Life Changes? *

Yes No
When was the last time you used and what did you use? *
What is the number of years you have been using? *
Education & Employment History
What is your highest level of education? *
Are you willing and able to work 40 hours a week? *

Yes No
Are you currently employed? *

Yes No
If you are currently employed, what is the name of the company you work for? (enter N/A if you are unemployed *
If you are currently unemployed, are you actively seeking employment? *

Yes No Currently Employed
If currently unemployed, what type of work are you looking for? *
What are your job skills? *
What potential job leads do you have? *
If you have any active licenses or certifications, please list them. Otherwise enter "None" *
Do you have in your possession a current picture identification? *

Yes No
Do you have in your possession your Social Security card? (not a copy) *

Yes No
Medical

The questions in this section are not used to determine your suitability in the Life Changes program and are never disclosed without your express written consent. Your answers will simply allow us to determine what Life Changes facility best suits your needs should you be accepted to the program.
Are you currently using any prescription medication? *

Yes No
Are you currently using any over the counter medications *

Yes No
Have you ever been diagnosed with a medically based disability? *

Yes No
If yes, what is your diagnosis? If No, simply enter N/A
If you answered yes to the above question, what accommodation do you need? Please explain in detail as Life Changes provides all reasonable accommodations to residents of the program. If you answered no to the above question, please enter N/A *
Have you ever been diagnosed with a mental health disability? *

Yes No
If yes, what is your diagnosis? If No, simply enter N/A
If you answered yes to the above question, what accommodation do you need? Please explain in detail as Life Changes provides all reasonable accommodations to residents of the program. If you answered no to the above question, please enter N/A *
Help & Assistance

This section will help us determine the type of services you may need while at Life Changes
Do you have any immediate needs such as clothing or toiletries? *

Yes No
Do you need assistance with any self-help, support group and/or networks within the local community? *

Yes No
Please define the additional assistance you may need to the best of your ability. *
Do you need assistance dropping classes, GED, vocational training resources? *

Yes No
Do you need assistance obtaining a birth certificate, valid state ID or Social Security Card? *

Yes No
Do you need assistance obtaining Medicaid or Food Stamps? *

Yes No
Do you need assistance creating a resume and/or Master Job Application *

Yes No
Do you need assistance accessing resources for employment? *

Yes No
Criminal Justice History
Are you a participant in any of the following Specialty Programs? Please select all that apply, or N/A if you are not involved in a Specialty Program. *

Parole/Probation Drug Court Veterans Court Family Court Mental Health Court DUI Court Federal Pre Trial Services
Who is your Parole, Probation or Court Services Officer?
What is your Parole, Probation of Court Services Officer Phone #

Area Code Phone Number
Are you currently involved in any legal proceedings or criminal justice issues? *

Yes No
If yes, please describe in detail
Do have any court ordered treatment requirements? *

Yes No
Do you have any pending sentencing or possible jail time upcoming? *

Yes No
Have you ever been charged or convicted of Arson? *

Yes No
Have you ever been charged or convicted of any violent crimes in any jurisdiction? *

Yes No
Have you ever been charged or convicted of abuse or neglect of any person, including but not limited to disabled person, senior, or child? *

Yes No
Have you ever been charged or convicted of cruelty to animals? *

Yes No
Are you affiliated with any gang? *

Yes No
Are you required to register as a sex offender *

Yes No
Select all circumstances that apply to you *

House Arrest Parole Probation Specialty Court
Are you required to register with any other authority for any reason? *

Yes No
Are there any No Contact or Restraining Orders against you or by you? *

Yes No
Financial

Life Changes, Inc. is a fee based program. Unless you have made arrangement to pay for your services through a third party, you are responsible to pay your service fees, including your intake fees. Without a third party payee source, you must have the finances or a reasonable plan to pay your fees. Stating you are "going to get a job" is not considered a reasonable plan. Should you find employment and your employer is willing to verify that you have a concrete start date and provide your rate of pay and pay dates, this MAY qualify you to receive services.
Type of Insurance *

Medicaid - Health Plan of Nevada Medicaid - Anthem Blue Cross/Blue Shielf Medicaid - Silver Summit Health Plan Medicare Private Insurance Not Insured
If you are not currently employed, what is your plan for paying your intake service fees? *
Have you made arrangements for a third party to pay your service fees? *

Yes No
If yes, please provide the name and contact information for the third party. *
Do you currently owe any past due fines or fees? For example, court fines, restitution, child support, etc. *
Applicant Statement

Please answer the following questions as mindfully and thoroughly as possible.
Why do you think the Life Changes, Inc. program would be a good fit for you? *
How did you hear about our program? *
Were you referred to Life Changes, Inc? *

Yes No
If you were referred by a case manager or criminal justice professional, please enter their name and phone number below. If you are self-referring, please enter "self" *
What three goals do you hope to achieve in the next 90 days?
Goal 1 *
Goal 2 *
Goal 3 *
What other information should we consider when reviewing your application? *
Please describe what issues led you to seek housing with Life Changes, Inc. Be specific as to how, when, where and what your role in the situation was. *
Covid-19

Upon completion of the COVID-19 self-assessment, if you believe you are at risk of having contracted COVID-19 or have been exposed, please discontinue processing this application and immediately seek medical attention.
COVID-19 Self-Assessment Screening

This tool is not meant to take the place of consultation with your health care provider or to diagnose or treat conditions. If you're in an emergency medical situation, call 911 or your local emergency number.

Information about COVID-19 is constantly changing. The level of COVID-19 activities varies by community, as does the availability of testing. For current update on COVID-19 and details on testing and other health measures in your area, check with your local public health agency and visit the CDC website at cdc.gov.
Please check all that apply *

Have you been within 6 feet of a person with a lab-confirmed case of COVID-19 for at least 5 minutes, or had direct contact with their mucus or saliva, in the past 14 days? In the last 48 hours, have you had any of the following NEW symptoms? 1. Fever of 100 F (37.8 C) or above, or possible fever symptoms like alternating chills and sweating 2. Cough 3. Trouble breathing, shortness of breath or severe wheezing 4. Chills or repeated shaking with chills 5. Muscle aches 6. Sore throat 7. Loss of smell or taste, or a change in taste 8. Nausea, vomiting or diarrhea 9. Headache 10. None of the above
I understand and agree that I am responsible for my own health and well-being and that it is my responsibility to reach out if I am feeling ill, have symptoms such as a fever, dry cough or am feeling nauseous, lose my sense of taste or smell or any other uncomfortable systems.

I understand and agree that should I be accepted into the Life Changes, Inc. congregate living facility, it is likely I will initially begin my residency in a quarantine facility and I agree to abide by all requirements of this facility.

I understand and agree that Life Changes, Inc. operates a congregate model of housing and agree to abide by any and all safety precautions suggested or regulated by the Centers for Disease Control, State of Nevada or Life Changes, Inc. I understand and agree that the COVID-19 pandemic and other health concerns is a viable issue and I will do my part to ensure the safety and well-being of myself, my house mates, staff, volunteers and visitors to the facility.
I am agreeing to these conditions of residency of my own accord. *

Yes No
Residential Rules & Code of Conduct
- Life Changes, Inc. is a suggested 90-day program. The monthly fees for the program are based on which facility best suites your needs. You must either have a third party payee source, or have the ability to pay your intake fees prior to entry.
  - Should you believe you would benefit from an extended stay, this must be requested in writing 30-days prior to your scheduled discharge date. Requests for extention will be considered on a case by case basis.
- I understand Life Changes is a faith-based program. As such, I agree to attend spiritual services/church. I understand this is a strict requirement of the program and should I be accepted I will comply with this requirement.
- I understand Life Changes operates a sober living home and drug or alcohol use is strictly prohibited. I also understand and agree to attend self-help meetings such as AA, NA, Celebrate Recovery, etc. while a resident of Life Changes, Inc. I understand this is a strict requirement of the program and should I be accepted I will comply with this requirement.
- As a Life Changes, Inc. participant, you are expected to comply with the following requirements.
  - Maintain a crime free lifestyle;
  - Obtain/maintain employment at 40 hours weekly (unless you have a valid medical reason not to do so and your fees are paid and kept current.
  - Pay your service fees, or be responsible for ensuring your designated third party pays your service fees;
  - Access behavioral and physical health services as recomended, and
  - Adhere to all program requirements, including requirements of the criminal justice system.
- Rules and Expectations
  - Alcohol/narcotic consumption, gambling, pornography and gang activity are prohibited on or off site as a resident of Life Changes. Non-compliance will result in immediate discharge.
  - All weapons are strictly forbidden.
  - Residents of Life Changes, Inc. agree to random urinalysis and breathalyzer resting.
  - Staff has the right to search your possessions if alcohol, narcotics, weapons, contraband, trafficking or thievery is suspected.
  - Thievery is not tolerated. Residents are responsible for their own possessions. Life Changes, Inc. is not liable for missing items.
  - Violence, including all forms of physical, mental, or emotional violence, intimidation, injury, abuse, negligent treatment, maltreatment, or exploitation, including sexual abuse, or harassment is strictly forbidden. This includes but is not limited to verbal or physical conduct that creates an intimidating, hostile, offensive environment, or sexual in nature directed toward any resident, visitor, staff or volunteer of Life Changes.
  - Smoking is allowed in designated areas only.
  - You may not have visitors in your room. All visitation is to take place in common areas. This applies to other house mates.
  - You may not use the phone for an excessive length of time if another resident needs access. You must answer incoming calls on call waiting while you are on the phone.
  - Residents are required to use the sign in/out sheets when leaving the facility. All fields must be completely filled out, legible, include your full name and your time of departure and anticipated return. You must use your legal name, NO NICKNAMES. If you are unable to return at your indicated time, you must contact staff to obtain permission to be late.
  - You are prohibited from eating in your room to ensure the facility stays free from pests
  - In the instance of illness, staff MUST be immediately notified. Residents must disclose to medical personnel that they are in recovery from an addictive disorder and may not be prescribed narcotics. Residents must provide staff with copies of all prescriptions and comply with all medication management policies and safe keeping requirements.
  - Upon discharge, you must remove all of your personal belongings. If your property is not removed within thirty days it will be considered abandoned and will be discarded. Life Changes is not responsible for items left on property.
  - You are required to attend mandatory self-help, and/or house governance and spiritual meetings.
  - You are required to adhere to curfew as indicated in your blackout, specific criminal justice or Life Changes requirements.
  - You are required to perform your chores daily, the kitchen is to be cleaned after each use, your bed must be made daily, your personal items put away and any food particles promptly disposed of.
  - You may NOT tattoo, use hair dye, paint, or otherwise perform any activity that may cause damage to another person or the facility.
  - You may not burn candles, incense or use personal space heaters at any time.
  - Do not borrow or loan, this includes money, cigarettes, clothes, personal belongings, food stamps or food.
  - You are required to be out of bed and ready for the day by 8 am MF. If you are employed and working swing shift, this requirement will be modified.
  - You are required to work or go to school a minimum of 40 hours a week.
  - You are required to pay your service fees and provide copies of your paycheck stubs to staff. Failure to pay your service fees in a timely manner is cause for dismissal.
    
    You are required to provide documentation of a legitimate job, with a schedule and set pay schedule.
Your signature below indicates you have read and understand the requirements of placement in the Life Changes, Inc. program.
Signature *

Clear
I understand this application for residency in no way commits me to the Life Changes program, nor does it commit Life Changes to accept me for residency. By submitting this application for residency, I confirm that all statements and information contained herein are true to the best of my knowledge. *

Yes No
Admission

One of our Intake Specialists will be in touch with you to discuss your application, service fees, required deposit and any other questions or concerns you may have. Please keep in mind, if you have not answered all questions on this application for residency, it will not be processed.
When would you like to move it? *

Month Day Year
Date
Are you aware that Life Changes, Inc. is a fee based organization and you are required to pay a deposit prior to intake? In addition, you are required to pay a $100 non-refundable administrative fee. Do you understand and agree? *

Yes No
Form Submission

STOP! If you have not answered every question on this form, your application WILL NOT BE PROCESSED. By submitting this application you attest that you have responded to each question truthfully and to the best of your ability, that you have read ALL rules and requirements and should you be accepted you will abide by these rules and requirements.
If a Third Party is submitting this application on your behalf, do we have your permission to speak to the Third Party? *

Yes No Not Applicable
Third Parties Name

First Name Last Name
Third Parties Phone Number

Area Code Phone Number
Third Parties Email
example@example.com
Should be Empty:

Application for Residency

General Information

Substance Abuse

Education & Employment History

Medical

Help & Assistance

Criminal Justice History

Financial

Applicant Statement

Covid-19

Residential Rules & Code of Conduct

Admission

Form Submission