• TRANSITIONAL HOUSING APPLICATION

    Freedom House Transitional Home

  • *Your application is completely confidential.  All information is stored in a secure environment and used only for purposes related to your admission.

     

    Please fill out entire form and don't leave anything blank.  If a question doesn't apply to you simply put N/A in the text box for Non-applicable.  Thank you!

     

  • Your Information:

  • Format: (000) 000-0000.
  • Gender*
  • Select All That Apply:*
  • Veteran of the U.S. Military Services?*
  • Are you a U.S. Citizen and are you legal to work in the U.S.?*
  • Are You Being Referred By An Agency? (CYFD, Court Compliance, Hospital, Detox, etc)*
  • Referring Source Requirement*

  • Emergency Contact Info:

  • Format: (000) 000-0000.

  • Criminal Offense History

    This will not disqualify you; please be honest!
  • Do you have any outstanding warrants?*
  • Are You A Registered Sex Offender?*
  • Are you on probation?*
  • Do you have a Protection Order in place?*
  • Do You Have ANY Pending Charges in other Counties?*

  • Well Being

  • Have You Experienced Any Seizure Activity Within The Last 12 Months?*
  • Are You Pregnant?*
  • Do you currently have any medical conditions which require special care?*
  • Are you currently on any medications?*
  • Are you homeless?*
  • Do You have any children?*

  • Mental Health History

  • Personal mental health history (Check all that apply):*
  • Select all that apply that you are currently experiencing:*
  • Have you ever worked with a mental health provider (psychiatrist, psychologist, therapist)?*

  • Waiver To Release Application Status

  • Authorization:

    I hereby authorize to release information regarding my application status, estimated wait time, transitional home acceptance, and intake for the purpose of collaboration and coordination of services to any affiliated facilities, my attorney, caseworker, Parole/Probation officer, Counselor, and family. If you are filling out the form for someone put your name & info as well as relation to the individual. Application must be completed by the individual seeking help before acceptance. I also authorize the following people to obtain my application status:

  • Disclosures:

    I understand that Freedom House Transitional Home cannot guarantee that the recipient will not disclose my application status to a third party. I understand that I can revoke my waiver at any time and for any reason. I understand that my Authorization will automatically expire one year from the date of my signature unless I request it be revoked earlier (see below). By submitting this application, I approve Freedom House Transitional Home and their affiliated facilities to disclose their company name when attempting to contact me. Access to FLC House Premises and Spaces Not a tenancy Residence at Freedom House is a central component of the Program. You understand that you are a licensee of FLC, and not a tenant. You are not signing a lease, FLC is not your landlord, and residency at Freedom House will at no time confer tenancy rights. FLC may terminate your residency for violation of this Agreement AT ANY TIME. FLC retains the right of control over and access to all Freedom House properties and units. Probationary period. Your participation in the Program is probationary for the first 28 days. FLC may extend this period at its discretion. During the probationary period, if FLC staff determines that you are not able to participate fully in the Program, you will be dismissed. At the end of the probationary period, if you have complied with all Program rules set out in this Agreement and all goals set out in your Action Plan, you will be accepted as a Program participant and resident of Freedom House. Abandonment of premises: You must notify the Program Director in advance of any extended leave away from Freedom House. FLC may discard items belonging to FLCs who are missing from Freedom House for more than 48 hours without notice. Absent prior notice, FLC has no obligation to and may not hold your bed beyond this point. Room Rules Cleanliness You must keep your space clean. You must also dispose of your garbage and recyclable materials properly. Damages and Repairs. You are responsible for any damage to your space and for any damage you may cause elsewhere on the premises. FLC will deduct any repair expenses from your Savings Account. Deductible expenses include, but are not limited to, physical repairs, furniture repair, key replacement, lock changes and stolen property. Entry FLC has the right to inspect your space at any time. Staff may perform a health and safety check of each space each month. On occasion, potential or current funders may tour FLC House. This may include a tour of your living quarters. FLC House employees and agents may also enter and inspect your space and common areas at any time to check that you are in compliance with this Agreement. The presence of FLC staff at your space will not limit or affect in any way your obligation to comply with this Agreement. This Section also does not impose any duty on FLC to inspect your space, report to anyone the results of any such inspection, or assume any liability of any kind arising from engaging or not engaging in such an inspection. Keys and Locks For safety purposes, please inform staff of lost card keys, space keys and mailbox keys immediately. If you lose your key, FLC will charge you a replacement fee, which will increase if you lose your card key subsequent times. Locks may not be placed on any doors or windows except by Freedom House Staff. You consent to and understand you will have video and audio recording in common areas of all FLC locations that may be used to confirm allegations made by other residents.

  • Acknowledgment of Approved and Prohibited Items:

    It is Freedom House Transitional Home policy that any prohibited items are not allowed on property at any time without prior written approval from the Program Manager. Prior to admission, a thorough search of your person and property will be conducted. Possession of any of the prohibited items may result in revocation of your application and/or admission status. Possession of any prohibited items after the admission process is completed may result in your immediate discharge from the home.

  • Transitional Home Outline:

  • Housing requirements at the different locations may differ.

    FH1- Long Term Faith Based Program- All residents will have a three week grace period to find employment. The resident program fee will be based on income 20% all living expenses 10% to tith making a total of 30% Basic requirements of the transitional home include but are not limited to random drug testing, meetings, church, attendance, and completion of the case management plan.

     

    NO DRINKING, DRUGS OR NO SMOKING AT THE TRANSITONAL HOME OF ANY KIND WILL BE TOLOERATED.

     

    FH2- Emergency Shelter Beds- No cost

    FH2- Long Term Transitional Beds- 20% case to case basis.

    FH3 - Emergency Shelter Beds- No Cost

    FH4- Long Term family/womens beds- Case by Case basis based on employment.

     

     

  • DISCLOSURE:

    I understand that Freedom House Transitional Home cannot guarantee that the recipient will not disclose my application status to a third party. I understand that I can revoke my waiver at any time and for any reason. I understand that my Authorization will automatically expire one year from the date of my signature unless I request it be revoked earlier (see below). By submitting this application, I approve Freedom House Transitional Home and their affiliated facilities to disclose their company name when attempting to contact me.

    Access to FLC House Premises and Spaces Not a tenancy Residence at Freedom House is a central component of the Program.

    You understand that you are a licensee of FLC, and not a tenant. You are not signing a lease, FLC is not your landlord, and residency at Freedom House will at no time confer tenancy rights. FLC may terminate your residency for violation of this Agreement AT ANY TIME.

    FLC retains the right of control over and access to all Freedom House properties and units.

    Probationary period. Your participation in the Program is probationary. FLC may extend this period at its discretion. During the probationary period, if FLC staff determines that you are not able to participate fully in the Program, you will be dismissed IMMEDIATELY WITH NO NOTICE. At the end of the probationary period, if you have complied with all Program rules set out in this Agreement and all goals set out in your Action Plan, you will be accepted as a Program participant and resident of Freedom House.

    Abandonment of premises: You must notify the Program Director in advance of any extended leave away from Freedom House. FLC may discard items belonging to FLCs who are missing from Freedom House for more than 48 hours without notice. Absent prior notice, FLC has no obligation to and may not hold your bed beyond this point.

    Room Rules Cleanliness: You must keep your space clean. You must also dispose of your garbage and recyclable materials properly.

    Damages and Repairs: You are responsible for any damage to the space you occupy and for any damage you may cause elsewhere on the premises. FLC will deduct any repair expenses from your Savings Account. Deductible expenses include, but are not limited to, physical repairs, furniture repair, key replacement, lock changes and stolen property.

    Entry: FLC has the right to inspect your space at any time. Staff may perform a health and safety check of each space each month. On occasion, potential or current funders may tour FLC House. This may include a tour of your living quarters. FLC House employees and agents may also enter and inspect your space and common areas at any time to check that you are in compliance with this Agreement. The presence of FLC staff at your space will not limit or affect in any way your obligation to comply with this Agreement. This Section also does not impose any duty on FLC to inspect your space, report to anyone the results of any such inspection, or assume any liability of any kind arising from engaging or not engaging in such an inspection.

    Keys and Locks: For safety purposes, please inform staff of lost card keys, space keys and mailbox keys immediately. If you lose your key, FLC will charge you a replacement fee, which will increase if you lose your card key subsequent times. Locks may not be placed on any doors or windows except by Freedom House Staff.

    Audio & Visual Recording: You consent to and understand you will have video and audio recording in common areas of all FLC locations that may be used to confirm allegations made by other residents.

  • Understanding:

    By signing this form: You acknowledge that you will adhere to all the rules and expectations, church attendance if required (FH1 ONLY), meeting, attendance, case, planning, etc. You acknowledge that you understand the Freedom House's and Transitional Homes and it's affiliated partners are not responsible or liable for any loss or injury that occurs well on the property or in the program. You acknowledge that you have read through the policies and procedures section on our website and the disclosures on this form.
  • Date*
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