The 11:59 House Intake Form
Name
*
First Name
Last Name
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Best time to reach you
Morning
Afternoon
Evening
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Please indicate your race/ethnicity (select all that apply)
Americal Indian or Alaska Native
Asian
African American
Caucasion
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Two or more races
Prefer not to answer
Do you identify as a member of the LGBTQ+ community?
Yes
No
Emergency Contact Name
*
Emergency Contact Phone Number
*
Preferred county
Please Select
Wilson
Rocky Mount
Please list the names and ages of anyone else who will be living with you.
Have you ever been convicted of a crime? Please note, answering yes does not automatically disqualify you.
*
Yes
No
Do you have any criminal convictions pending? Please note, answering yes does not automatically disqualify you.
*
Yes
No
City and state of conviction:
If you answered yes to the above questions, please explain:
Are you transitioning from any of the following situations?
Rehabilitation
Homelessness
Substance Abuse Recovery
Recently Incarcerated
Domestic Violence Shelter
Mental health Facility
Do you currently have a case manager, social worker, or program contact?
*
Yes
No
If yes, please provide their name and contact info
Do you currently or have you ever used any illegal substances?
*
Yes
No
If yes, please explain.
Do you have any mental illnesses?
*
Yes
No
If yes, please list diagnoses.
If so, has this been diagnosed by a physician?
Yes
No
Are you currently prescribed any medications?
*
Yes
No
Do you self-administer? Please note, we are not a medical facility and cannot administer medication.
*
Yes
No
Would you benefit from medication reminders? A staff member can remind you when it's time to take your medication.
Yes
No
Do you have any physical limitations or accessibility needs?
*
Yes
No
If yes, please explain so we can do our best to accommodate you.
Which are you applying for?
*
Shared Room (starting at $750)
Private Room (starting at $950)
Whichever is available for immediate move in
Are you currently employed?
*
Yes
No
If employed, how many hours per week?
Hourly pay rate
Employer's name
Employer's address
Pay Frequency
*
Weekly
Biweekly
Monthly
Other
N/A
If unemployed, what is your source of income?
How much are your paid/receiving monthly?
*
Next Pay Date
*
-
Month
-
Day
Year
Date
Do you have identification?
Yes
No
When are you planning to move?
*
Immediately
Within 1-2 weeks
Within 2-4 weeks
Later than one month
Please note, there is a $300 one time program fee that will be due to hold your requested room. Rent is due the day of move in and will be prorated if you move in after the 1st of the month. Do you understand and agree?
*
Yes
No
By agreeing below, I certify that the information provided is true and complete to the best of my knowledge. I understand that The 11:59 House is a drug- and alcohol-free environment and that all residents must follow the program rules and policies to remain in good standing.
*
Yes
No
Submit
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