Zera House Resident Application
Applicant Information
Full Name:
Date of Birth:
-
Month
-
Day
Year
Date
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Current Address:
Emergency Contact Name and Phone Number:
Referral Information
Are you being referred by an agency, program, or case manager?
Yes
No
Agency/Organization Name:
Case Manager or Referral Contact:
Phone Number:
Format: (000) 000-0000.
Program History
Have you previously been in a residential or recovery program?
Yes
No
If yes, please briefly explain:
Have you previously lived in transitional housing?
Yes
No
If yes, where?
Medical & Mental Health Information
Are you currently taking any medications?
Yes
No
Are you currently taking any mental health medications?
Yes
No
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Do you have any serious medical conditions or health concerns that we should be aware of?
Yes
No
If yes, please briefly explain:
Have you ever received mental health treatment or counseling?
Yes
No
If yes, please briefly explain:
Have you ever received substance abuse treatment?
Yes
No
If yes, please briefly explain:
Safety & Support
Are you currently in a safe place?
Yes
No
Do you currently have any pending legal issues or court obligations?
Yes
No
If yes, please explain briefly:
Do you currently have identification?
Driver's License
State ID
Social Security Card
Birth Certificate
None
Employment & Income
Are you currently employed?
Yes
No
Employer:
Monthly Income (if any):
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Personal Goals
Why are you seeking placement at Zera House?
What goals would you like to work on while in the program?
Applicant Agreement
I understand that submitting this application does not guarantee placement at Zera House. I certify that the
information provided is true to the best of my knowledge.
Applicant Signature:
Date:
-
Month
-
Day
Year
Date
Contact Information
If you have any questions regarding this application or the Zera House program, please contact:
Mikey Epling
Executive Director, Zera House
Email: mikey.zerahouse@gmail.com
Phone: 304-306-1887
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