Xchange Recovery Supportive Housing Application
  •  - -

  • XChange Recovery Supportive Housing Application

    Please complete this application honestly and thoroughly – incomplete applications will not be considered. Program fee required upon entry.****Acceptance Criteria: have a substance use disorder, pass a panel interview, and provide a clean UA upon entry. 

  • IF YOU ARE IN A FACILITY (TREATMENT, DETOX, MENTAL HEALTH FACILITIES, OR IN A HOSPITAL PLEASE FILL OUT THEIR ROI (Release of Information) BEFORE CONTINUING SO WE CAN GET AHOLD OF YOU FOR FOLLOW UP (Please Sign the ROI for XChange!)

  • Sex at birth:*
  •  -
  •  -

  • Current Situation

  • Reason(s) you need housing - Check all that apply. Explain if necessary*

  • Are you currently in a treatment or other facility?*
  • Are you currently homeless?*

  • Have you stayed at a shelter in the past two years?*

  • Background Information

  • Are you a US Citizen?*

  • Do you identify with a certain culture?

  • EMERGENCY CONTACT INFORMATION:

    (Please list three)

  •  -
  •  -
  •  -
  • Are they one of the contacts listed above?
  •  -

  • How many siblings?

  • Did Any of the following occur in your household while growing up? (Check all that apply)*

  • Relationships

  • Marital Status (select all that apply):*
  • Do you expect or hope for reconciliation with your spouse?
  • Do you expect or hope for reconciliation with your ex?
  • How do you identify your sexual orientation?*

  • Children

  • Are you pregnant?*
  • Are you the legal guardian of your children?
  • Do all your children live with you?
  • Child protective services:
  • Were children removed?*
  • Required to attend mandatory Parenting Classes?*

  • Domestic Violence

  • Have you ever been a victim of domestic violence?*
  • Restraining/Protective Order in Effect?
  • Who do you use for emotional / social support? (Check all that apply)*

  • Employment Information

  • Current Employment Status (check all that apply):*
  • Frequency of Pay for this job
  • Frequency of Pay at Agency
  • Are you looking for work?

  • Please list your last four employers (include dates employed and reason for leaving)

  • Other Income

  • Do you have funds to come into our program (minimum of $600)?*
  • Do you receive any of the following?*

  •  -

  • Education

  • Do you have a high school diploma?*
  • Do you have a GED?*
  • Are you interested in getting your GED?
  • Do you have any college education?
  • Do you have a learning disability?*
  • Do you plan to go back to school or any other educational institution?*

  • Substance Abuse

  • Substances you use*

  • Do you have an active prescription for Aderal or other Amphetamines?
  • Do you have an active prescription for Opioid pain killers?
  • Do you have an active prescription for Barbituates?
  • Do you have an active prescription for Benzos?
  • Do you have an active prescription for Lunesta, Ambien or other Roofies?
  • Do you have an active prescription for Suboxone/Subsolve?
  • Do you have an active prescription for Methadone?
  • Do you have an active prescription for Naltrexone?
  • Do you attend 12-step meetings?*
  • How Often?

  • Legal History

  • Have you had contact with the legal/court system within the last 24 months?*
  • Have you ever been convicted of a sex offense or arson charge?*
  • Are you currently incarcerated?*
  • Have you been incarcerated in the past?*
  • Are you currently on probation or parole?
  • Have you ever been convicted of a crime?*
  • Do you have any current/ pending legal issues or lawsuits?*
  • Do you have legal financial obligations?*

  • Medical History

  • Do you have any current medical conditions or have seen a doctor for anything in the last 60 days?*
  • Do you have medical insurance?*
  • What insurance?*

  • Do you take any medications? (prescriptions/ non-prescription)*
  • Have you been prescribed any medications you are not taking?*
  • Do you have allergies that require an Epi Pen?
  • Are you on a Medicated Assisted Treatment Program (MAT) Suboxone or Vititrol?*
  • Suboxone ?
  • Have you ever been hospitalized?*
  • Do you have any mental or physical issues that keep you from working?*

  • Mental Health History

  • Have you ever thought of or attempted suicide?*
  • Have you ever seen a counselor for anything?*
  • Have you ever been diagnosed with any mental health issues? (Depression, anxiety, ADHD, bipolar, schizophrenia, etc.)*
  • Are you currently participating in mental health treatment?*
  • Are you taking any mental health medications currently?*
  • Have you taken different mental health medications in the past?*

  • Transportation

  • Do you have a valid drivers license?*
  • Do you own a vehicle?*
  • Do you have liability insurance?

  • Residences

  • Do you have another previous address?
  • Do you have another previous address?
  • Do you have another previous address?
  • Do you have another previous address?
  • Do you have another previous address?

  • Housing

  • Do you plan to stay in Clark county?*
  • How did you hear about Xchange Recovery? (check all that apply)*

  • Do you have friends or family that currently live in Xchange Recovery housing or are affiliated with Xchange Recovery?*

  • Goals and Objectives

  • Please review your application to make sure it has been completed thoroughly and to the best of your ability. We understand you may not recall a phone number, address or specific date, however, applications missing critical information will not be considered.

  • Should be Empty: