Resident Application

Section 1

Applicant Information

Applicant Name *

Phone *

Email *

Street Address

City

State

Zip

Date of Birth

Pronouns

Gender

Male Female Other

Physically Independent?

Yes No

Emergency Contact 1

Primary Contact

Name

Relationship

Phone

Address

City

State

Zip

Emergency Contact 2

Secondary Contact

Name

Relationship

Phone

Address

City

State

Zip

Section 4

Substance Use History

History of alcohol or drug use?

Yes No

Date of Last Use

Longest Period of Abstinence

Past Treatment (Inpatient, Outpatient, Rehab, Residential, etc. — with dates)

Section 6

Economic Resources

SSI — Amount / month

SSDI — Amount / month

Welfare

Food Stamps

Medicaid #

Medicare #

Veterans Affairs #

Tricare #

Employment Plans (if applicable)

How will you pay for accommodations?

SSI SSDI VA Private Pay

Section 7

Lifestyle

Residents are required to pay a non-refundable $150 processing fee to cover administrative costs and maintenance for the entirety of each stay. This is due prior to or on the day of moving in. A copy of your ID and proof of income are also required.

I have read and understand the above terms.

Signature (type your full name) *

By typing your name, you certify that all information provided is accurate to the best of your knowledge.

Applicant Information

Primary Contact

Secondary Contact

Behavioral History

Substance Use History

Health Conditions

Economic Resources

Lifestyle