Recovery Residence - Application for Housing

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* 1. Contact Information

Name *

Male of Female

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address *

Phone Number *

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* 2. Date of Birth

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* 3. Please indicate how you heard about our program. (Check all that apply)

Alumni

Internet

Housing Organization

Case Worker

Frieds/Family

Religious Organization

Criminal Justice System

Other (please specify)

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* 4. Please answer the following questions to the best of your ability.

	Yes	No
Are you currently pregnant?	Are you currently pregnant? Yes	Are you currently pregnant? No
If so, are you over 20 weeks pregnant?	If so, are you over 20 weeks pregnant? Yes	If so, are you over 20 weeks pregnant? No
Do you have full custody of your children? (if no, you must obtain proof of the amount of time you are allowed visitation)	Do you have full custody of your children? (if no, you must obtain proof of the amount of time you are allowed visitation) Yes	Do you have full custody of your children? (if no, you must obtain proof of the amount of time you are allowed visitation) No
Are you currently on probation or parole?	Are you currently on probation or parole? Yes	Are you currently on probation or parole? No
Have you been convicted of a sex offense?	Have you been convicted of a sex offense? Yes	Have you been convicted of a sex offense? No
Are you are registered sex offender?	Are you are registered sex offender? Yes	Are you are registered sex offender? No
Do you have an extreme violent history? (example: aggravated assault or kidnapping charges)	Do you have an extreme violent history? (example: aggravated assault or kidnapping charges) Yes	Do you have an extreme violent history? (example: aggravated assault or kidnapping charges) No
Have you been evicted from housing in the last year due to non-payment?	Have you been evicted from housing in the last year due to non-payment? Yes	Have you been evicted from housing in the last year due to non-payment? No
Have you been denied housing due to poor house keeping habits or bed bugs?	Have you been denied housing due to poor house keeping habits or bed bugs? Yes	Have you been denied housing due to poor house keeping habits or bed bugs? No
Are you on any Medical Assisted Therapy? (Methadone, Suboxone, Etc.)	Are you on any Medical Assisted Therapy? (Methadone, Suboxone, Etc.) Yes	Are you on any Medical Assisted Therapy? (Methadone, Suboxone, Etc.) No

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* 5. Please list your most recent treatment for substance abuse.

Name of Center

Address

Level of Care (example: Residential, Day Treatment, Intensive Out Patient, etc.)

Dates Attended

Did you graduate?

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* 6. Please indicate how long you have been sober.

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* 7. Do you require any special needs or assistive devices?

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* 8. Employment

Name of Company

Address

Phone Number

Position

Supervisers Name

Salary

How long have you been employed?

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* 9. Housing Reference 1

Name of past landlord

Phone Number

Dates you were there

Rented or owned?

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* 10. Housing Reference 2

Name of landloard

Phone Number

Dates you were there

Rented or Owned?

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* 11. Personal Reference 1 (other then relatives)

Name

Phone Number

Relationship

Years know

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* 12. Personal Reference 2 (other then relatives)

Name

Phone Number

Relationship

Years known

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* 13. Emergency Contact

Name

Phone Number

Relationship

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* 14. Vehicle Identification

Year

Make

Model

License Plate Number

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* 15. Submission Clause By submitting this application I certify that to the best of my knowledge, all information is true and correct. I further authorize The Haven to make inquires as necessary to verify all information in this application and to determine eligibility for Recovery Residence. I understand that providing false information may be grounds for denial of services. Please type your name below if you agree to terms and conditions. ***All persons will be treated fairly and equally without regard to race, gender, color, religion, handicap/disability, sexual orientation or gender identity.