Contact Information

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* 1. Contact Information

Date of Birth

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* 2. Date of Birth

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

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

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

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

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

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

Please indicate how long you have been sober.

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

Do you require any special needs or assistive devices?

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

Employment

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* 8. Employment

Housing Reference 1

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* 9. Housing Reference 1

Housing Reference 2

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* 10. Housing Reference 2

Personal Reference 1 (other then relatives)

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* 11. Personal Reference 1 (other then relatives)

Personal Reference 2 (other then relatives)

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* 12. Personal Reference 2 (other then relatives)

Emergency Contact

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* 13. Emergency Contact

Vehicle Identification

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* 14. Vehicle Identification

***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.

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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.

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