Form
Waiting List
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Prefer not to say
Do we have permission to call the number above?
Yes
No
Best time to reach you?
Morning
Afternoon
Evening
Anytime
Do you speak or understand English fluently?
*
Yes
No
Which best describe you?
*
Veteran
Domestic Violence Survivor
In Recovery (Substance Use or Mental Health)
Recently Released from Incarceration
Seeking a Fresh Start with Support
Other
Race
*
Caucasion
African American
Hispanic
Other
How long have you been in this situation?
*
Have you been diagnosed with or experienced any mental health-related challenges?
Yes
No
If yes, please list any mental health conditions you're currently managing.(Example: Depression, Anxiety, PTSD, Bipolar Disorder, etc.)
Are you currently taking any prescribed medication for your mental health condition(s)?
Yes
No
Do you have any physical health conditions or disabilities we should be aware of?
Do you have Income?
*
Yes
No
If yes, what is your income source?
*
How much are you receiving monthly?
What type of room do you prefer?
*
Private
Shared
Do you have a support system (family, mentor, caseworker, etc.)?
*
Yes
No
If yes, who?
*
Why are you interested in Hazel's Haven?
What are 1–2 personal goals you'd like to work on while here?
Do you have reliable transportation?
*
Yes
No
Working on it
Have you been previously incarcerated?
*
Yes
No
If yes, are you currently on probation or parole? (This does not disqualify you from the program. We ask only to better understand your support needs.)
*
Yes
No
Emergency Contact (Name, Phone Number, Relationship to You)
Do You Need Assistance with Any of the Following? (This helps us understand how to best support your transition and connect you with helpful resources.)
Applying for SNAP (Food Stamp) Benefits
Applying for SSI/SSDI
Applying for VA Benefits
Accessing Clothing Donations
Medication Pick-Up or Reminders (Note: We do not administer medications)
Obtaining a State ID or Birth Certificate
Job Search Support or Resume Help for better Job
Setting Up a Bank Account
Other
Are you interested in faith-based support or mentorship while in the program?
Yes
No
If accepted, when would you be ready to move in?
How Did You Hear About Us?
Referral from Shelter or Program
Social Media
Word of Mouth
Flyer or Event
Other
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