Second Wind Living Application
Welcome to Second Wind Living. We’re so glad you’re here. This application helps us understand your needs so we can match you with a home that feels safe, supportive, and truly yours. Please complete the form as thoroughly as you can. If you’re unsure about a question, just write “N/A” where it applies—there’s no judgment here. Every answer helps us create the kind of environment where you can breathe easier, feel respected, and begin your next chapter with dignity.
Name of person completing form
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First Name
Last Name
Phone Number of person completing form
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Please enter a valid phone number.
Applicant's First & Last Name
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First Name
Last Name
Applicant Contact Number or TDCJ #
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Date of birth
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-
Month
-
Day
Year
Date
Sex
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Male
Female
Speaks what language?
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Mental Capacity: Is the individual able to make sound decisions independently?
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Level of Care: Can the individual independently manage activities of daily living (bathing, grooming, toileting, eating, transferring)? If not, please specify which ADLs require assistance.
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Is the applicant a U.S. citizen?
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Yes
No
Will the individual be released with a state ID, Social Security card, or birth certificate? Please select what the indiviual will have.
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State ID
Social Security Card
Birth Certificate
Will Need to Obtain
Unsure
Veteran Status: Is the individual a veteran?
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Yes
No
Financial Benefits:
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Social Security
State Income Supplemental
Veterans/Disability
Company Pension
Other
SSI/SSDI Status: Has the individual been approved for or reinstated on SSI/SSDI? Are there any outstanding obligations to Social Security? (If an application has been submitted, please share the current status.)
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Medical and Mental Health: Are there any major medical conditions or known mental health diagnoses?
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Medication: Is the individual currently taking any medication?
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Please Select
Yes
No
Unsure
Individual smokes?
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Yes
No
Unsure
Individual drinks?
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Yes
No
Unsure
If yes, is to either question. Is there a drug or alcohol issue/problem?
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Yes
No
Unsure
Mobility: Do they use any mobility aids (walker, wheelchair, rollator, cane)?
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Who is managing finances?
Self
Spouse
Family
Friend
Trustee
Power of Attorney
Other
Discharge Type: Is the discharge flat or parole? If on parole, please include the duration.
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Offense Date
Offense
Sentence Date
County
Case No.
Sentence (YY-MM-DD)
Share whatever details you have—we’ll handle the rest with compassion and discretion.
At this time, is the applicant aware of any "SPECIAL" conditions to their probation? Select all that apply.
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Treatment Programs
Community Service
Curfew
Monitoring (Such as ankle monitor)
Unsure
Other
If 'other' was selected, please explain.
Is there someone else we should contact about your application? Such as a Responsible Party or Representative.
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