Transitional Living Assistance Request Form
This form must be completed to the best of your ability, to be considered for funding.
What is your Name?
*
First Name
Last Name
Do you have an Email? (Not your case manager's)
*
Yes
No
Your Email?
*
example@example.com
Your Date of Birth?
*
/
Month
/
Day
Year
Date
What Gender are you?
*
Please Select
Male
Female
what is your Race?
*
Please Select
Hispanic or Latino
African American
Caucasian
Native American
Asian
Other Race
What city and state are you in?
*
Street Address Line 2
City
State
Postal / Zip Code
Are you on disability?
Please Select
Yes
No
Which statement best describes the reason for the assistance requested:
*
I'm in treatment/detox and need assistance for new residence
I'm in a transitional living and need additional funding
I'm coming from jail/prison and need assistance for new residence
Other
Have you previously been to a transitional living facility?
Please Select
Yes
No
Which transitional living facility were you previously at?
*
Which Treatment Center are you at right now?
*
Please Select
Clean Recovery Center
Rockland treatment center
CRC (Community Recovery Center)
Banyan Treatment Center
Turning Point of Tampa
ACTS Keystone
River Oaks
Baycare ISU
White Sands
Catchers Mitt
Cove Behavioral Health
Mandala Healing Center
Outfield
Spring Garden
Other
Other Name of Treatment Center not listed
*
Which Jail/Prison are you coming from?
*
Please Select
Pasco County Detention Center
Pinellas County Jail
Florida Women's Reception Center
Taylor Correctional institution
Hamilton Correctional Institution
Volusia County Jail
Hernando County Detention Center
Putnam County Jail
Lancaster Correctional Institution
Other
Other Jail/Prison not listed?
*
Discharge planners/Re-entry coordinator Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Extension Number
Please enter the extension
What is your Discharge date?
*
-
Month
-
Day
Year
Date
What is the Reason you are requesting additional assistance for transitional living?
*
Please specify the reason for this request that is not listed?
*
What is Your phone number?
*
Please enter a valid phone number.
Format: (000) 000-0000.
Which Transitional Living are you at or going to?
*
Women at the Well
Ruth House
Boaz House
Ace Opportunities
Harmony House
Pathways Recovery Home
The Boat Yard
Real Recovery New Port Richey
Steps To Recovery
ARC Pasco
The Rope Center
Victory House
Oxford House Peace River
Oxford House Land O Lakes
Oxford House Gulf Oasis
Oxford House Grace Valley
Da Vinci Recovery Homes
ARC Pinellas
Real Recovery Brandon
Real Recovery Bradenton
Real Recovery Clearwater
Real Recovery North Tampa
Real Recovery St Petersburg
Other
Other transitional living house not listed?
*
What is your drug of choice?
*
Opiates
Meth
Cocaine
Marijuana
Alcohol
Benzos
Other
Other Drug of Choice not listed?
*
Do you have a history of Overdoses
*
Yes
No
Do you have a disability/physical limitation that will prevent you from working?
*
Yes
No
Are you homeless?
*
Yes
No
Do you have health insurance?
*
Yes
No
Do you have EBT?
*
Yes
No
Do you have driver's license?
*
Yes
No
Do you have identification card?
*
Yes
No
Do you have birth certificate?
*
Yes
No
What city and state were you born?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have social security card?
*
Yes
No
Are you taking any medication(s)?
*
Yes
No
What medication(s) are you prescribed?
*
Have you ever been tested for HIV or Hepatitis C?
*
Yes
No
Would you be interested in free testing?
*
Yes
No
Are you a veteran?
*
Yes
No
What branch did you serve?
*
Time frame of active duty?
*
Were you deployed in support of combat?
*
Yes
No
Do you need any of the following services
*
Detox treatment
Outpatient treatment
Inpatient treatment
Mental health services
Other
Other services requested not listed
*
IF YOU RECEIVE ASSISTANCE FROM THE HOPE SHOT, YOU WILL BE ASSIGNED A RECOVERY COACH AND WILL BE REQUIRED TO ENGAGE WITH YOUR COACH. IF YOU AGREE TO THIS, PLEASE SIGN BELOW?
*
By acknowledging the above statement, please print name for signature above.
JotForm
True
Referred from Account
Please Select
Pasco County Detention Center
Pinellas County Jail
Florida Women's Reception Center
Taylor Correctional institution
Hamilton Correctional Institution
Volusia County Jail
Hernando County Detention Center
Putnam County Jail
Lancaster Correctional Institution
Clean Recovery Center
Rockland treatment center
CRC (Community Recovery Center)
Banyan Treatment Center
Turning Point of Tampa
ACTS Keystone
River Oaks
Baycare ISU
White Sands
Catchers Mitt
Cove Behavioral Health
Mandala Healing Center
Outfield
Spring Garden
Other
Other Referred
Submit
Submit
Should be Empty: