New Start Sober Living Supportive Housing
Currently, we are exclusively processing housing applications for unaccompanied individuals, both men and women. Regrettably, we are unable to facilitate housing arrangements for couples, pets, or families with children at this time. Please understand that our housing options are designed for shared living arrangements, not for individual occupancy. We appreciate your cooperation and hope you'll consider our program. Thank you for your understanding.
Applicant Full Name?
Applicant Phone Number?
Applicant Email?
Application Date?
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Month
-
Day
Year
What location are you applying for?
Who Is The Application for?
Please Select
Myself
Family Member
A client (I am - Case worker, referral agency, social worker or sponsor)
Gender?
Male
Female
Other
Date Of Birth
-
Month
-
Day
Year
Are you aware that this is a shared living home?
Please Select
Yes
No
Have you lived in shared housing before?
Please Select
Yes
No
Why did you leave?
Current Living Situation?
Please Select
Group Home shared living
Living with family
Living by myself
Living With Roommates
Homeless with no permanent place to live
Current Address?
How long would you like to be a guest at our home?
Please Select
1 - 3 months
4 - 6 months
7 - 12 months
1 - 2 years
Funding Source
Self Pay
Voucher
Social Security Insurance
Social Security Disability Insurance
Government or State Organization
Non Profit Organization - Rent Assistance
Are you Employed?
Please Select
Yes
No
If you are employed, what are your hours/shift and what city do you work in?
Would you consider appointing a Representative Payee to ensure timely rent payments aiding the success of your housing? If not, your rent will be due in advance to assure good faith.
Please Select
Yes
No
Criminal History
Please Select
I Have A Felony
I Have A Misdemeanor
I Have No Criminal History
If yes, please provide details of any criminal charges or convictions you have, including the nature of the charges and any associated legal outcomes.
Funding Source Details : 1. Amount Received 2. Date of Payment: 3. Additional Income Information?
Please disclose any existing medical conditions or health concerns that we should be aware of.
Do you have any food or drug allergies? If yes, please elaborate.
Are you currently taking any medications?
Please Select
No
Yes - Prescription medication
Yes - Over the counter medication
If yes, please provide a list of the medications you are taking, including their names and dosages.
Primary Mode of Transportation?
Please Select
Public Transportation
Personal Vehicle
Do you smoke?
Please Select
Yes
No
If yes, what do you smoke?
Do you agree to a drug test prior to your move-in date?
Please Select
Yes
No
Do you agree to random drug tests?
Please Select
Yes
No
We have house rules to govern the safety and harmony of the home? Would you abide by them?
Please Select
Yes
No
Preferred Move In Date?
-
Month
-
Day
Year
Any important details we should be aware of, not yet addressed?
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I realize that the New Start Sober Living to which I am applying for residency has been established in compliance with the conditions of §2036 of the Federal Anti-Drug Abuse Act of 1988, P.L. 100-690, as amended, which provides that federal money loaned to start the house requires the house residents to:
(A) prohibit all residents from using any alcohol or illegal drugs,
(B) expel any resident who violates such prohibition,
(C) equally share household expenses including the monthly lease payment, among all residents, and (
D) utilize democratic decision making within the group including inclusion in and expulsion from the group. In accepting these terms, the applicant understands that §2036 conditions are different than the normal due process afforded by some local landlord-tenant laws.
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