Stay Safe Homes-Program Application
Application for Services This is a safe space. We offer help without judgment, confidentiality is guaranteed, and your past will never disqualify you from receiving support.
Apply Today
Your honest answers are essential for us to provide you with the most accurate assistance
How many adult applicants are applying?
1
2
Applicant 1 Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Gender
*
Please Select
Male
Female
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White/Caucasian
Co Applicant 2 Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Gender
*
Please Select
Male
Female
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White/Caucasian
Program Interest
Eligibility for our programs requires that an adult household member has a history of, or is currently managing, substance use and/or mental health challenges.
Select the program you are interested in
*
Home Sharing Recovery Program
Families In Recovery Program(IF YOU HAVE CHILDREN SELECT THIS PROGRAM) (Eligible households must consist of three members, including at least one child)
If you are applying for Families In Recovery Program, please indicate the number of children in your household
*
1
2
I am not applying for Families In Recovery Program
If you are applying for Families In Recovery Program please provide the age and gender of the child(ren)
What date did you need placement by?
Applicant 1 History
Substance Abuse History
Your honest answers are essential for us to provide you with the most accurate assistance
What substance(s) have you struggled with?
*
Please Select
Drugs
Alcohol
Both
None
If you have struggled with substance, please list all substances you have used or struggled with:
Most recent use of alcohol or drugs
-
Month
-
Day
Year
Date
Drug of Choice?
Do you need any detox placement
*
Yes
No
Mental Health History
Your honest answers are essential for us to provide you with the most accurate assistance
Have you ever received a diagnosis or sought support for any of the following?(select all that apply)
*
Anxiety
Depression
Postpartum Depression
PTSD
Bipolar Disorder
Schizophrenia
None
Other
If you chose other, please specify your condition
Employment
Your honest answers are essential for us to provide you with the most accurate assistance
Are you currently employed?
*
Please Select
Yes
No
Source of Income (select all that apply):
None
Social Security/Disability
Child Support
TANF
Unemployment Benefits
Child Support
Veteran Benefits
Retirement
Tribal per cap
If you are not employed, are you actively seeking employment?
*
Yes
No
I am employed
Housing
Your honest answers are essential for us to provide you with the most accurate assistance
Please describe your current living situation
*
Own Home
Roommate
Shelter
Sober Living Home
Group Home/Behavioral Health Home
IOP Supportive Housing Home
Live with family/Friends
Homeless
Renting a room
Treatment program
Sleeping in Car
Other
If you chose other, please describe in detail
Treatment
PLEASE ANSWER ALL QUESTIONS HONESTLY AS THIS IS THE ONLY WAY, WE CAN ASSIST YOU
Please indicate if you are currently receiving any form of support for your well-being.
*
Yes, for mental health
Yes, for substance use
Yes, for both
No, I am not currently receiving support
If yes, what date did you START your most recent treatment?
-
Month
-
Day
Year
Date
If yes, what date did you END your most recent treatment?
-
Month
-
Day
Year
Date
Please list all treatments you have ever received (select all that apply)
*
Sober Living Home
Behavioral Health Residential Home/Residential Treatment
IOP Supportive Housing
Detox
Intensive Outpatient Program (IOP)
Partial Hospitalization Program (PHP)
Outpatient Treatment (OP)
Counseling
N/A
Other
If you chose other, please describe in detail
Questionnaire
Reason for Applying
*
0/100
How would this opportunity help you?
*
Applicant 2 History
Substance Abuse History
Your honest answers are essential for us to provide you with the most accurate assistance
What substance(s) have you struggled with?
*
Please Select
Drugs
Alcohol
Both
None
If you have struggled with substance, please list all substances you have used or struggled with:
Most recent use of alcohol or drugs
-
Month
-
Day
Year
Date
Drug of Choice?
Do you need any detox placement
*
Yes
No
Mental Health History
Your honest answers are essential for us to provide you with the most accurate assistance
Have you ever received a diagnosis or sought support for any of the following?(select all that apply)
*
Anxiety
Depression
Postpartum Depression
PTSD
Bipolar Disorder
Schizophrenia
None
Other
If you chose other, please specify your condition
Employment
Your honest answers are essential for us to provide you with the most accurate assistance
Are you currently employed?
*
Please Select
Yes
No
Source of Income (select all that apply):
None
Social Security/Disability
Child Support
TANF
Unemployment Benefits
Child Support
Veteran Benefits
Retirement
Tribal per cap
If you are not employed, are you actively seeking employment?
*
Yes
No
I am employed
Housing
Your honest answers are essential for us to provide you with the most accurate assistance
Please describe your current living situation
*
Own Home
Roommate
Shelter
Sober Living Home
Group Home/Behavioral Health Home
IOP Supportive Housing Home
Live with family/Friends
Homeless
Renting a room
Treatment program
Sleeping in Car
Other
If you chose other, please describe in detail
Treatment
PLEASE ANSWER ALL QUESTIONS HONESTLY AS THIS IS THE ONLY WAY, WE CAN ASSIST YOU
Please indicate if you are currently receiving any form of support for your well-being.
*
Yes, for mental health
Yes, for substance use
Yes, for both
No, I am not currently receiving support
If yes, what date did you START your most recent treatment?
-
Month
-
Day
Year
Date
If yes, what date did you END your most recent treatment?
-
Month
-
Day
Year
Date
Please list all treatments you have ever received (select all that apply)
*
Sober Living Home
Behavioral Health Residential Home/Residential Treatment
IOP Supportive Housing
Detox
Intensive Outpatient Program (IOP)
Partial Hospitalization Program (PHP)
Outpatient Treatment (OP)
Counseling
N/A
Other
If you chose other, please describe in detail
Submit
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