Application for Placement

1
Email* This field is required.
example@example.com
2
Client's Gender* This field is required.
Male
Female
Transgender
3
Client's Name* This field is required.
First Name
Last Name
4
Representative's Name* This field is required.
First Name
Last Name
5
Rep's Organization (ex: United Way, VA, etc)* This field is required.
6
Client's Phone Number* This field is required.
Please enter a valid phone number.
7
Do we have permission to text/leave a message on the number provided?** This field is required.
YESNO
8
Date of Birth* This field is required.
Date
Month
Day
Year
9
Race* This field is required.
Caucasian
African American
Asian
Pacific Islander
Native American
Other
10
Client's Current Living Situation* This field is required.
Living with family/friend
Living in car
Living in a shelter
Living on the street
Incarcerated
Hospital/Facility
Shared Housing/Group Home
11
When does client need to be placed?* This field is required.
Date
Month
Day
Year
12
What type of room does the client prefer* This field is required.
Shared
Private
13
How will the client pay?* This field is required.
SSI/SSDI
Retirement
Voucher
Organization Funding
Job
Other
14
How much income do you receive monthly? If none please type NONE* This field is required.
15
Does the client suffer from mental illness?* This field is required.
YESNO
16
If answered yes, list mental diagnoses* This field is required.
17
Are you disabled?* This field is required.
YESNO
18
List disability(s)* This field is required.
19
Does client require a Handicap Accessible living environment?* This field is required.
YESNO
20
Is the client an ex-offender?* This field is required.
YESNO
21
Have you been convicted as a Sex Offender? (Your answer to this questions does not disqualify you from our program & services)* This field is required.
Yes
No 2
With 1000ft restriction
Without 1000ft restriction
22
Are you currently on Probation or Parole?* This field is required.
YESNO
23
Do you need help with recovering from Opioid(s) and/or other drugs and alcohol?* This field is required.
YESNO
24
Will the client have children living with them? (Please list ages)* This field is required.
25
Select all of the services you are requesting.* This field is required.
Transportation Assistance
Job Placement
Apply for SNAP benefits
Apply for SSI/SSDI
Organizational Payee
Health Insurance Enrollment
Clothing Donation
Life Skills/ Recovery Groups
Day Program
Group Therapy
Cellphone/Tablet Assistance
26
How did you hear about us?* This field is required.
Referral
Search Engine/ Web
Word of Mouth
Other
Should be Empty: