Restored and Revived - Housing Project Application
Please complete the form to apply for R&R housing program.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Birthdate
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Non-Binary
Not disclose
Not listed Above
Trans-Female
Trans-Male
Two-Spirit
Race
*
Please Select
Black/African American
White/Caucasian
American Indian/Alaskan Native
Hispanic/Native
Multi-Racial
Pacific Islander
Asian
Did not disclose
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Method of Contact (Phone/Text/Email):
*
Phone Call
Text
Email
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Sobriety & Recovery
Sobriety Date:
*
-
Month
-
Day
Year
Date
Drug of Choice:
Date of Last Use (if applicable):
-
Month
-
Day
Year
Date
What Do you currently do for your Recovery:
*
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Legal & Criminal History
Have you been convicted of a crime?
*
Please Select
Yes
No
If yes, please explain:
Are you currently on probation or parole?
*
Please Select
Yes
No
If yes, name of officer:
Contact info for officer (if known):
Any open CPS cases?
*
Please Select
Yes
No
If yes, explain briefly:
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Housing History
Have you had previous evictions?
*
Please Select
Yes
No
If yes, how many and when?
What is the longest amount of time you’ve stayed in one place?
*
Have you ever lived in Oxford House or any other housing program?
*
Please Select
Yes
No
If yes, which one(s)?
Have you ever been asked to leave or been removed from a housing program?
*
Please Select
Yes
No
Please explain honestly: (This will not disqualify you. We believe in second chances, but honesty is required.)
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Children & Family
Do you have children?
*
Please Select
Yes
No
Do they live with you?
Please Select
Yes
No
Do they visit?
Please Select
Yes
No
How often?
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Employment & Support
Are you currently employed?
*
Please Select
Yes
No
If yes, where?
How long have you worked there?
Who referred you to Restored & Revived?
*
Are you currently working with any agencies or organizations? If yes, list them here:
*
Do you have a current SUD (Substance Use Disorder) or MH (Mental Health) assessment?
*
Please Select
Yes
No
If yes, date of last assessment:
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Housing Barrier
What is your current barrier to housing? (Check all that apply and/or explain below)
*
Poor rental history
Criminal record
Lack of income/employment
Substance use history
Mental health challenges
Domestic violence
No ID or documents
Other:
Explanation (optional):
Additional Notes (optional)
Date
*
-
Month
-
Day
Year
Date
Record Type
Housing Status
*
Please Select
Applied
Submit
Should be Empty: