Program Application
Todays Date
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Month
-
Day
Year
Date
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Age
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Phone Number
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Email Address
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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 Partcipante)
Community Referral
Case Manager/ Social worker
Other
Case Manager Name, Organization, Email and Telephone Number (NA if not applicable )
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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
Parol/ Porbabtion
Hospital/ Treament Center
Family / Friend
Preferred Move In Date
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Month
-
Day
Year
Date
Desired Housing Location
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RALEIGH
DURHAM
CARY
WAKE FOREST
KNIGHTDALE
CHAPEL HILL
FUQUAY-VARINA
Please list any medical history( if none type NA)
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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 none, 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
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
No Income
Other
Can you provide proof of income
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Yes
No
Monthly income amount ($)
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Do you have any disabilities or accommodations needed?
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Preferred Room Type
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Private Suite
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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