The Miracles Club Transitional House Interest Form
Do you have any additional questions? Email amee@miraclesrecovery.org
Participants Name
*
First Name
Last Name
Participants of Birth
*
-
Month
-
Day
Year
Date
Participants Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Release Date - If incarcerated
-
Month
-
Day
Year
Date
Last Date Of Use
-
Month
-
Day
Year
Marijuana & Alcohol included
Participants Email
If applicable
Which House are they interested in staying in?
*
Women - Identifying House
Men - Identifying House
Expressions House LGBTQia+2s
Washington County House "Port House"
Medical Conditions, Mental Health, History of drug & alcohol use (past & present) (diagnosis, concerns, if/where are they receiving services):
*
Please add any additional information needed, example* contact info, if partnered with someone also seeking shelter, etc.
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Referring Partner & Agency Information
All Participants Must have a Case Manager, PO, or be connected with another organization to be referred. The participant must agree to sign an ROI for referring partner to collaborate with The Miracles Club.
Referring Agency?
*
name of organization.
Name
First Name
Last Name
Direct Supports Name
*
First Name
Last Name
Length of Time You Have Been Working with the Participant?
*
Please Give Brief Description of Relationship with Particpant?
*
The Direct Support is intended to be a long standing support while they stay in Miracles Housing.
In what capacity are you working with the participant?
*
Housing
Case Management
Mental Health
Medical
Parole / Probation Officer
Other
Please list (If Other is Selected, above)
Direct Supports Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Direct Supports Email
*
example@example.com
Direct Supports Position
*
Other agencies engaged with participant & in what capacity (Please include contact info if available):
*
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Housing Information
Known barriers (criminal history, evictions/poor rental history, poor credit, low/no income, etc.):
*
Barrier resolutions already in place (Rent Well, expungement, debt repayment plans, etc.):
Does the Participant have an ID, Proof of Income (List below)?
*
Example* Participant has ID, is awaiting social security & has no income
Monthy Income Amount
*
Input the number "0" , if no income
Source of Income
*
Input n/a if not applicable
Employment Status
*
Employed
Unemployed, seeking work
Unemployed, not looking for work
Disabled
Submit
Should be Empty: