Pinnacle Pathway Center LLC Resident Application
Complete this resident application, ensuring to provide all required information. This application is solely for housing with Pinnacle Pathway Center LLC (PPC). All information provided will be used exclusively to determine eligibility and placement within PPC housing programs and will not be shared or used for any other purpose.
Applicant Information
Application Date
-
Month
-
Day
Year
Date
Referred By
Legal Name
*
First Name
Middle Name
Last Name
Suffix
Preferred Name / Nickname
Pronouns
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Social Security Number
Gender Identity
Woman
Man
Non-binary
Transgender
Questioning
Another identity
Primary Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Street Address
*
City / State / ZIP
*
How long at current address - Years
How long at current address - Months
Current Living Situation
*
Own home
Renting
With family
With friends
Shelter
Transitional housing
Treatment facility
Unhoused
Other
Current Living Situation - Other (describe)
Race / Ethnicity
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Another identity
Emergency Contacts
Contact #1 Full Name
*
First Name
Middle Name
Last Name
Contact #1 Relationship
*
Contact #1 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact #1 Alternate Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Contact #1 Email
example@example.com
Contact #1 City / State
Contact #2 Full Name
*
First Name
Middle Name
Last Name
Contact #2 Relationship
*
Contact #2 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact #2 Alternate Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Contact #2 Email
example@example.com
Contact #2 City / State
Contact #3 Full Name
First Name
Middle Name
Last Name
Contact #3 Relationship
Contact #3 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Contact #3 Alternate Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Contact #3 Email
example@example.com
Contact #3 City / State
Military / Veteran Information
Are you a U.S. Military Veteran
*
Yes
No
Branch of Service
Army
Navy
Air Force
Marine Corps
Space Force
Coast Guard
Other
Date of Service - Entry into the Military
-
Month
-
Day
Year
Date
Date of Service - Exit from the Military
-
Month
-
Day
Year
Date
Total Years Served
Character of Discharge
Discharge Status
*
Honorable
General Under Honorable Conditions
Other Than Honorable
Bad Conduct
Dishonorable
Pending/Unknown
Other
Service-Connected Disability
*
Yes
No
Pending
Unknown
VA Disability Rating (%)
*
VA Healthcare Enrolled
Yes
No
Pending
Unknown
VA Medical Center
Military Occupational Specialty (MOS / Rate / AFSC)
Deployment History
Yes
No
Unknown
Deployment Location(s)
Combat Experience
Yes
No
Prefer not to say
Unknown
Current VA Benefits Received
Healthcare
Disability Compensation
Education Benefits
Housing Assistance
Pension
Other
Current VA Benefits - Other (describe)
Currently experiencing MST-related challenges
Yes
No
Prefer not to say
Unknown
Recovery & Substance Use History
Have you ever experienced challenges with alcohol or substance use?
*
Yes
No
Prefer not to say
Primary substance(s) of concern
*
Alcohol
Cannabis
Opioids
Stimulants
Sedatives / Sleep Medications
Nicotine
Other
Primary substance(s) - Other (describe)
Are you currently in recovery?
*
Yes
No
Prefer not to say
Length of recovery - Years
*
Length of recovery - Months
*
Length of recovery - Days
*
Date of last use
*
-
Month
-
Day
Year
Date
Have you completed formal treatment?
*
Yes
No
Prefer not to say
Treatment facility
Treatment type
Please Select
Detox
Inpatient Rehabilitation
Outpatient Program
Intensive Outpatient Program
Medication-Assisted Treatment
Therapy / Counseling
Other
Treatment completion date
-
Month
-
Day
Year
Date
Current Support Group Participation
AA
NA
SMART Recovery
Refuge Recovery
Faith-Based Group
Peer Recovery Group
Other
Support Group - Other (describe)
Meeting frequency
Please Select
Daily
Several times per week
Weekly
Biweekly
Monthly
Less than monthly
As needed
Other
Do you have a sponsor or recovery mentor?
Yes
No
Prefer not to say
Sponsor / Mentor name and contact
Have you relapsed after a period of recovery?
Yes
No
Prefer not to say
Strategies developed to prevent future relapse
Are you interested in becoming a Certified Peer Support Specialist (CPSS) during residency?
*
Yes
No
Maybe
Mental & Physical Health
Diagnosed with a mental health condition
*
Yes
No
Mental health diagnoses
*
Depression
Anxiety
Bipolar disorder
PTSD
Schizophrenia
Substance use disorder
Other
Mental health diagnosis - Other (describe)
Currently receiving mental health treatment
*
Yes
No
Therapist / Provider name
Provider phone
Please enter a valid phone number.
Format: (000) 000-0000.
Appointment frequency
Please Select
Weekly
Biweekly
Monthly
As needed
Other
Currently taking prescribed medications
*
Yes
No
Medication list
Physical health conditions or disabilities requiring accommodation
*
Yes
No
Description of physical health conditions or disabilities
Dietary restrictions or allergies
*
Yes
No
Description of dietary restrictions or allergies
VA Program Services
Housing support
Clinical services
Benefits assistance
Peer support
Case management
Other
Education, Employment & Technology
Highest education level completed
*
Current certifications / licenses
Transportation access
*
Please Select
Own vehicle
Public transit
Rideshare
Family/Friend support
Walking
Other
Computer literacy level
*
Please Select
None
Basic
Intermediate
Advanced
Internet and email access
*
Please Select
Reliable access
Limited access
No access
Other
Smartphone access
*
Please Select
Yes, own phone
Shared phone
No access
Other
Telehealth capable
*
Please Select
Yes
No
Sometimes
Other
Current career interests
Workforce interest areas
Customer service
Food service
Construction
Healthcare
Administrative support
Warehouse / logistics
Retail
Skilled trades
Technology
Other
Workforce interest - Other (describe)
Current employment status
*
Please Select
Employed full-time
Employed part-time
Unemployed
Student
Retired
Unable to work
Other
Employer name
Position / job title
Length of employment
Supervisor name / phone
If unemployed, actively seeking employment
Yes
No
Not applicable
Would you like job-search and career coaching assistance from Pinnacle
*
Yes
No
Maybe
Primary barriers to employment
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