Touchstone Housing Application

  • Pathway Solutions LLC

    HOUSING APPLICATION

  • Only 18 and up can apply 

    *** No pets allowed***

  • Before we can consider your application for a bed in our homes, we kindly ask you to complete our application Form. This form is an essential part of our intake process, allowing us to better understand your needs and how we can support you on your journey to a brighter future.

    Once you've completed the form, our team will review your information and get in touch with you within 5-10 business days to discuss the next steps. Rest assured, your privacy and confidentiality are of utmost importance to us.

  • Please let us know how you heard of us:*
  • Were you referred by someone currently in the program?If yes, please provide their full name:This helps us thank them and apply their referral credit.*
  • What Services would you be interested in?*
  •  / /

  • APPLICANT INFORMATION

  •  - -
  • Format: (000) 000-0000.
  • Do you have a car?*
  • Do you smoke?*
  • Do you or your spouse have any kids?*
  • Do you have any special needs or requirements the we need to be aware of?*

  • Roommate Compatibility and Hygiene

  • Have you ever lived with a roommate and shared a room with bunk beds?*
  • Are you comfortable with following established room cleanliness and tidiness guidelines, such as a cleaning schedule or roommate agreement??*

  • Self-Identification

  • Male or Female?*
  • What are your pronouns?*
  • How do you describe your sexual orientation?*

  • Emergency Contact Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Covid 19 Screening- Current health conditions

  • Are you willing to be Tested for Covid before entry?*
  • Have you been exposed to covid in the last 2 months?*
  • Have you tested positive for Covid in the last 2 months?*
  • Do you have fever, aches, pains, sore throat and or a cough?*
  • Are you willing to have a physical before entry?*
  • Are you currently taking any over the counter or  doctor prescribed medication?*
  • Do you have any allergies?*
  • Have you’ve tested positive for any of the  following:*
  • Have you ever been diagnosed with, or are currently being treated for any of the following conditions?*
  • Have you ever been diagnosed with any psychological disorders?*
  • Are you physically independent?*

  • CRIMINAL HISTORY

  • Are you currently on probation or parole?*
  • Have you, ever been charged (whether or not resulting in a convicted, or pleaded guilty or "no contest" to a felony?*
  • Have you ever been convicted of or pleaded guilty or "no contest" to a misdemeanor involving sexual misconduct or the manufacturing of drugs whether or not resulting in a conviction?*
  • Are you required to register as a Violent or Sex Offender in a jurisdiction?*

  • Behavioral History

  • Do you have a history of attempted suicide or thoughts of suicide?*
  • Do you have a history of violent or assaultive  behavior?*
  • Do you have a history of malicious behavior such  as fire setting or retaliation?*

  • Substance Abuse History

  • Do you have a history of drug abuse of the following*
  • Do you use any of these drugs recreationally?:*
  •  - -
  • Have you ever received any substance abuse  treatment in the past (IP, OP, Residential, etc.)*

  • EMPLOYMENT INFORMATION

    (Current and/or Most Recent Type  N/A if this does not apply)
  • Are you currently employed or previously employed?*
  •  - -

  • Resources/Assistance/Methods of payment

    (This housing program has associated fees or costs)
  • Do you receive any of the following:*
  • What method of payment will you use to cover the expenses during your stay at Reintegration Haven Homes?*

  • ATTESTATION

  • I hereby certify that the answers I have given in the application are true to the best of my knowledge. I understand that any false answers or statements made by me will be sufficient grounds for including termination of association and removal from Reintegration Haven homes. I agree to a credit check if deemed necessary. I agree that my present employer may release information related to my current income status to the landlord. It is understood that I will not be discriminated against based on race, color, sex, religion, or national origin.

     

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  • Our partner REINTEGRATION HAVEN HOMES

    (773) 234-6253
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