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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Driver's License OR State ID Number
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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/ Probation Officer
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
Other
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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Are you a veteran?
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YES
NO
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 a smoker?
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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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Any Pending charges?
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Yes
No
Do you have a source of income?*
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Yes
No
Frequency of payment
Monthly
Weekly
Biweekly
Other
How will Monthly Program fee be funded (check all that apply)
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SSI
SSDI
Employment
Retirement
Pension
Community Source
State Special Assistance
HOP Funds/ Flexible Care Funds
Reentry Council Housing Voucher or Grant
Friend /Family Support
No Income
Other
Do you have a pet, service animal, or an emotional support animal (ESA)? (This does not automatically exclude you from the program. If yes, additional information may be requested during the screening process.)
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NO
Yes – Service Animal
Yes – Emotional Support Animal (ESA)
Yes- Pet
Other
Do you anticipate requesting, an assistance animal (including a service animal or emotional support animal) during your participation in the program?
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YES
NO
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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Mobility Needs
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Please Select
None
Cane
Walker
Wheelchair
Do you understand that Radiant Living4U provides Shared Housing? (Shared housing means you will be living in a home with other Radiant Living4U program participants. Common areas such as the kitchen, living room, bathrooms, and laundry facilities are shared. **IF IN A SHARED SUITE YOU WILL HAVE A ROOMMATE.)
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YES I understand and am comfortable with the shared housing model.
NO I withdraw my application
Preferred Room Type
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Private Suite (limited avilaibity)
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
Are you (applicate) comfortable living in a shared household and participating in house chores?
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YES
NO
Radiant Living4U enforces a strict zero-tolerance policy for drug and alcohol use. Are you (applicate) willing and ready to live in a 100% sober environment?
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YES
NO
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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