phoenix house of akron application

  • Phoenix House of Akron

    Priority Placement Housing Application
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you have a valid photo ID?*
  • Can you provide proof of identity at intake?*
  • Are you currently single?
  • Are you legally married?*
  • Are you currently living with a spouse, partner, or significant other?*
  • Are you willing to comply with a men-only housing environment?*
  • Are you willing to follow all guest and visitor rules?*
  • What type of setting are you coming from?*
  • Have you ever been evicted or discharged from housing, sober living, shelter, or a program?*
  • Are you applying for immediate placement or the priority waiting list?*
  • Are you self-referred or referred by an agency/program?*
  • Format: (000) 000-0000.
  • May we contact the referral source to verify information?*
  • Do you currently have income?*
  • What is your current source of income?*
  • Are you currently employed?*
  • Can you provide proof of income?*
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  • Do you currently have enough income to pay program fees at move-in?*
  • If you do not currently have income, are you being referred by an agency that will pay 2–3 months up front?*
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  • While agency funding is covering your first 2–3 months, are you willing to actively look for employment?*
  • Are you seeking a sober, recovery-focused living environment?*
  • Are you willing to live in a drug- and alcohol-free home?*
  • Date of last alcohol use*
     - -
  • Date of last illegal drug use*
     - -
  • Have you completed detox recently?*
  • Have you completed residential or outpatient treatment?*
  • Are you currently involved in counseling, treatment, MAT, probation programming, or case management?*
  • Are you willing to attend required recovery meetings, check-ins, or house meetings?*
  • Have you lived in sober living or recovery housing before?*
  • Are you willing to follow curfew, chore schedules, and house policies?*
  • Are you willing to submit to drug/alcohol screening if required by house policy?*
  • Are you willing to participate respectfully in a shared living environment?*
  • Can you live independently in a non-clinical peer housing setting without 24/7 supervision?*
  • Are you able to bathe, dress, cook basic meals, clean, and manage your own daily routine independently?*
  • Do you have transportation?*
  • Do you need help accessing work, treatment, probation, or appointments?*
  • Have you ever been convicted of a violent offense?*
  • If yes please provide a detailed explanation of the situation...*
  • Are you required to register as a sex offender?*
  • Are you currently on parole or pobation?*
  • If yes, do you have meeting times and scheduled home visits that we should be aware of?*
  • Do you have any conditions or needs that can affect living in transitional housing with other indiviuals?*
  • Should be Empty: