Silver Lining House Program Application
Qualifications to apply:
Please apply if you answer yes to the following questions:
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You are between 18-30.
You do not have any open "crimes against persons charges"
You have been drug/alcohol free for 90 days, or are completing a treatment program
You have read the program overview
To apply to our other programs, go to https://providencenetwork.org/gethelp/
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General Info
Name
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First Name
Middle Name
First Name
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Middle Name
*
Last Name
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Preferred Name
Alias and/or Maiden Name
Have you applied to or lived in a Providence Network home before?
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Yes
No
How did you hear about the program? Provide agency and/or person.
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Phone Number
*
Primary
Email
example@example.com
Age
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Birthdate
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-
Month
-
Day
Year
Date Picker Icon
Social Security Number
Type of Medical Insurance
Medicaid Number
Do you have a valid form of identification?
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Yes
No
Marital Status (check all that apply)
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Single
In a Relationship
Separated
Married
Engaged
Common Law
Divorced
Widowed
Race (check all that apply)
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Asian
Black
Hispanic.Latino
Native American/Pacific Islander
White
Prefer not to answer
Ethnicity
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Hispanic/Latina/o/Latin X
Non-Hispanic/Latina/o/Latin X
Prefer not to answer
Sexual Identity:
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Heterosexual
Gay/Lesbian
Bisexual
Other
Prefer not to answer
Gender Identity:
Military Service
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Yes
No
Where are you currently living?
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Shelter
With a friend
With family
Outside
Hotel/Motel
In another program
House or apartment that I rent
If you are in treatment, detox, or another program, what is your discharge date?
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Which describes your situation?
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NEWLY HOMELESS (Have experienced the following at least once in the last year): Sleeping in outside, in cars, shelters, transitional housing, or a hotel/motel paid by voucher
CHRONIC HOMELESS (Experienced 1 of the following for a duration of 1 year or at least 4 episodes of "homeless" in last 3 years.) Sleeping in outside, in cars, shelters, transitional housing, or a hotel/motel paid by voucher
AT RISK HOMELESS: Staying with family/friends, hotel/motel, jail/prison/halfway house, hospital or treatment center, facing eviction, other unstable housing situation
NEVER HOMELESS/STABLE HOUSING (always paying rent or a mortgage)
Last Stable Address
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County of Last Stable Address
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How long have you been in Colorado?
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Please list other states you have lived in:
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Current address or name of program:
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Who is your emergency contact?
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What is your relationship?
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Phone/Email:
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Important Contacts and Providers (check all that apply)
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CPS Social Worker
Probation/Parole Officer
Lawyer
Psychologist
Psychiatrist
Primary Care Physician
Other
None
Are you willing to sign a release of information for staff to speak with your providers for coordination of care?
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Yes
No
Not sure
Education/Employment/Income
Education (check all that apply)
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High School Diploma
GED
Did not complete High School or GED
Some college
Trade school or apprenticeship certificate
Associates Degree
Bachelor's Degree
Master's Degree
Doctorate Degree
Are you employed?
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Yes
No
Unable to work
If employed, add your employer, pay, and hours.
What are your barriers to finding employment?
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Total Monthly Income
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Types of income & cash benefits
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Monthly Amount
Comments
Employment
TANF
Child Support
SSI/SSDI
AND
Unemployment
Friend/Family Support
No income
Types of non-cash benefits: (check all that apply)
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SNAP
CCAP
WIC
Medicaid
Other
None
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Children
Do you have any children?
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Yes
No
Is there anything you would like us to know about your child/children?
Please tell us about visitation/custody arrangements and any legal orders.
Is CPS Involved?
Yes
No
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Legal
Be sure to include anything that may appear on your background check.
Legal History (check all that apply)
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I have an arrest record
I have been sentenced to jail or prison
I have criminal charges pending
I am on probation or parole
I have had a "crimes against persons" charge (violent or sexual offenses, DV charge)
I was involved in the juvenile justice system
I have never been arrested or had criminal charges outside of minor traffic offenses.
Types of criminal charges, past and present.
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Yes/No
Open, Closed, or Pending
Dates of Offenses
Notes
DUI/DWAI
Drug Charges
Theft/Identity
Assault/Harrassment
Domestic Violence
Weapon
Other
Other
Provide details about upcoming court dates and terms & location of probation/parole.
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Comments about your criminal charges:
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Substance Use
Drug/Alcohol History
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Within the past year
Within the past 5 years
More than 5-years ago
Never
Frequency (1 time, daily, weekly, occasional)
Date of last use
Alcohol
Pot
Cocaine
Meth
Heroin
Fentanyl/Opioids
Synthetics
Hallucinogens
Other
Other
Describe your history with substance abuse:
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What is your longest period of sobriety:
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What is your recovery/treatment plan? Are you receiving medicated assisted treatment? IOP?
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Who among your friends and family have drug or alcohol problems?
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Health/Medical
Check all medical conditions you have:
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Allergy
Asthma
Seizure Disorder
Diabetes
TBI
Heart Condition
Cancer
Other Chronic Health Condition
None
Check all mental health diagnoses you have received by a clinician:
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ADHD
Anxiety
Clinical Depression
Bipolar
Personality Disorder
Schizophrenia
Other
None
Provide details about medical and mental health conditions you have:
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List current medications
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Name
Purpose
Dose
Prescribing Doctor
Notes
Med 1
Med 2
Med 3
Med 4
Med 5
No Medications
Do you have any concerns about your medications or plan to change them?
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Personal Background & Areas of Need
Areas of difficulty or trauma:
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Within the past year
Within the past 5 years
More than 5 years ago
Never a problem
Learning Difficulty
Mental Health
Eating Disorder
Pornography
Disability
Self-Harm
Religious Abuse
Cult Involvement
Suicidal Thoughts
Suicide Attempts
Comments about your past or present difficulties:
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Treatment/Care History
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In the past year
Within the past 5 years
More than 5 years ago
Never
Counseling or Mental Health Care
Psychiatric Hospitalizations
Drug/Alcohol Treatment
Group Home/Foster Care
Please Describe circumstances and dates for your treatment/care experiences:
*
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Previous generations of my family have been involved with:
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Homelessness
Addiction
Domestic Violence
TANF Colorado Works
None
What do you feel is the cause of your present difficulties?
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What kind of help are you hoping our program can provide?
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Why do you need a structured program and not just housing?
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What are your main goals? (Education, employment, parenting, financial, etc.)
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What questions or concerns do you have about our program?
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Providence Network is a Christian faith-based community. We do not discriminate and welcome people from all backgrounds and beliefs. Do you have any questions, concerns or comments about this aspect of our program?
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Is there anything else you would like to tell us about yourself?
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