Vista Village Transitional Housing Program Application

1
How did you hear about Vista Village?* This field is required.If an agency referred you, please include the agency's name.
2
Are you aware Vista Village is a transitional housing program (18-24 months), not permanent housing?* This field is required.
YESNO
3
Are you aware that Vista Village is an alcohol-free, marijuana-free and illicit substance-free community?* This field is required.
YESNO
4
Are you aware that you may be tested at any time during your participation in the program and must pass to remain eligible?* This field is required.
YESNO
5
Name* This field is required.
First Name
Middle Name
Last Name
6
Date of Birth* This field is required.
Date
Month
Day
Year
7
Social Security Number* This field is required.
8
Gender* This field is required.
Male
Female
Other
Prefer not to say
9
Phone Number
Please enter a valid phone number.
10
Email* This field is required.
example@example.com
11
Address* This field is required.Please enter your current mailing address
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
Marital Status* This field is required.
Single
Married
Divorced
Widowed
Separated
13
If you have children, are you aware that they cannot live with you at Vista Village? The houses are single occupancy only. They can visit though!* This field is required.The homes are single occupancy only!
14
Military Status* This field is required.
Never in Military
Reserves
Active Duty
Veteran
Combat Duty
15
Discharge Type
Honorable
General
Medical
Dishonorable
N/A
16
Do you have a valid photo ID? If yes, DL/ID number:
Please Select
Please Select
Yes
No
ID Number
17
Do you have a birth certificate?* This field is required.
YESNO
18
Do you have a social security card?* This field is required.
YESNO
19
Preferred Language* This field is required.
20
Are you able to understand verbal and written English?* This field is required.
YESNO
21
Are you a US Citizen or Legal US Resident?* This field is required.
YESNO
22
Race* This field is required.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
23
Hispanic or Latino Ethnicity?* This field is required.
YESNO
24
Do you have a vehicle? If yes, describe.
Please Select
Please Select
Yes
No
Color, Make, Model
25
Are you currently homeless?If yes, why did you leave your last living arrangement? If no, proceed to next question.
Please Select
Please Select
Yes
No
If yes, please explain.
26
If you're not homeless, describe your current living situation.If this doesn't apply, proceed to next question.
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27
How many times have you been homeless, and what is the longest amount of time you have been homeless?* This field is required.E.g. 3 times, 1 year
28
What type of health insurance do you have?* This field is required.
Medicaid
Medicare
Private
None
29
Do you have any physical health conditions? If yes, please explain.
Please Select
Please Select
Yes
No
If yes, list conditions.
30
Doctor's name and phone number* This field is required.If none, where do you go for healthcare when you're not well?
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31
Do you have a mental health condition(s)?
Please Select
Please Select
Yes
No
If yes, please list condition(s).
32
Mental health provider's name and phone numberif applicable
33
Please list current medications for any physical or mental health condition(s).* This field is required.If none, type N/A.
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34
Do you have any allergies? If yes, describe.
Please Select
Please Select
Yes
No
If yes, describe allergy and reaction.
35
Do you have any history of substance use? If yes, explain.If yes, list substance(s), amount(s), and date of last use.
Please Select
Please Select
Yes, past substance use
Yes, current substance use
No
Substance(s), amount(s), and approximate date(s) of last use.
36
Have you ever been treated for substance use?If yes, list treatment provider(s) and approx. dates of treatment.
Please Select
Please Select
Yes
No
Treatment provider(s) and approx. date(s).
37
Date you last used:* This field is required.If not applicable, type N/A.
38
How long have you been sober since you first decided to quit using substances? If you have had any relapses, please share how long you have maintained sobriety in your most recent attempt.* This field is required.Type N/A if not applicable.
39
Do you attend AA/NA meetings? If yes, how many each week? If no, what do you do to maintain your recovery?if applicable
Please Select
Please Select
Yes
No
Number of meetings each week
If none, how do you maintain your recovery?
40
Are you willing to take a drug test to enter and/or remain in the Vista Village program?* This field is required.
YESNO
41
Are you currently employed? If yes, how many hours per week? If no, how come?
Please Select
Please Select
Yes
No
If yes, how many hours per week?
If no, how come?
42
Current or most recent employmentIf none, type N/A
Company
Job Title
Start Date
End Date
Hourly Pay
43
Have you ever been fired from a job?If yes, describe circumstances.
Please Select
Please Select
Yes
No
If yes, describe circumstances.
44
Please describe any other previous employment/training/volunteer experience:* This field is required.If none, type N/A.
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45
Do you have difficulty reading or writing?* This field is required.
YESNO
46
Do you have a high school diploma or GED?* This field is required.
YESNO
47
If you don't have a high school diploma or GED, what is the highest level of education completed? * This field is required.Type N/A if not applicable
48
Do you have any college credits and/or vocational/technical training? If yes, please describe.
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49
Have you ever been incarcerated?* This field is required.If yes, list all institutions and dates served. If none, type N/A.
Please Select
Please Select
Yes
No
Institution and dates served
50
List all legal history* This field is required.Please include arrests and convictions, as well as county of arrest, for misdemeanors and felonies. If none, type N/A. Please note, a criminal offense does not disqualify you from program participation.
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51
Are there any pending charges/outstanding warrants against you?
Please Select
Please Select
Yes
No
If yes, describe.
52
Are you on parole or probation?If yes, provide name/phone of officer.
Please Select
Please Select
Yes
No
Officer name and phone number
53
Have you ever been evicted from housing? If yes, list each eviction and describe the circumstances.* This field is required.
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54
What do you know about Vista Village and what questions do you have? * This field is required.
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55
What are your personal goals for the next 18-24 months?* This field is required.
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56
Please describe what you hope to gain from Vista Village.* This field is required.
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57
What steps have you taken to address the challenges that contributed to your experience of homelessness? Please include any efforts you've made on your own, as well as any case management or supportive services you’ve received from organizations or individuals.* This field is required.If none, type N/A.
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58
Do you have any supportive people in your life? If yes, tell us about them.* This field is required.If no, type N/A.
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59
Is there anything else you want to tell us?
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