Program Application
Today's date
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Month
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Day
Year
Date Picker Icon
First Name
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Last Name
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Date of Birth
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Month
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Day
Year
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Age
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Social Security Number (Last 4 digits)
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Phone Number
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Email Address
Do we have permission to email, text or leave a message on the number provided?
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Yes
No
Gender
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Male
Female
Non-binary
Prefer Not to Say
Other
This form is being completed by
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Myself (the participant)
Community Referral
Case Manager / Social Worker
Other
Case Manager Name, Organization, Email and Telephone Number
Emergency Contact Name
Emergency Contact's Phone Number
Relationship to Emergency Contact
Current Living Situation
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Homeless
Staying with Others
Transitional Housing
Jail/Prison Release
Hospital/Rehab
Other
Referral Source (If Applicable)
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Self
Agency
Parole/Probation
Hospital or Treatment Center
Family/Friend
Preferred Move In Date
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Month
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Day
Year
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Desired Housing Location
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Saint Louis County
Saint Louis City
Saint Charles County
Please list any medical history
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Do you have a history of any mental health conditions
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Yes
No
If answered yes, please explain. If answered no, please type n/a
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Substance use history (if any):
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Alcohol
Drugs
None
If answered yes, please explain. If answered no, please type n/a
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Are you willing and able to comply with living in a drug- and alcohol-free environment?
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Yes
No
Are you currently on parole or probation
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Yes
No
If answered yes, please explain. If answered no, please type n/a
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Are you a registered sex offender
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Yes
No
Do you have a source of income?
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Yes
No
Income Source
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SSI
SSDI
Employment
Retirement
Pension
Community Source
Other
No Income
Can you provide proof of income
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Yes
No
Monthly income amount ($)
Do you have any disabilities or accommodations needed?
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Preferred Room Type
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Private Sute
Semi-private/Shared Suite
Can you live independently and manage your Activities of Daily Living (ADLs) without assistance?
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Yes
No
Do you currently have or need a home health care provider or outside support service?
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Yes
No
I understand and agree that this program provides housing only. I will be responsible for my personal care, medical needs, and daily living tasks.
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I Understand
I Do Not Understand
I understand that if accepted, I must follow all house rules, expectations, and participate in case management or program-related check-ins.
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I Agree
I Disagree
I acknowledge that violating rules may result in a strike or dismissal from the program.
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I Agree
I Disagree
I certify that the above information is true to the best of my knowledge. I understand that this application does not guarantee placement, and my application will be reviewed by staff.
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I Agree
I Disagree
Name
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First Name
Last Name
Submit
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