Application

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Personal Details

Name(Required)

First Middle Last

Have you ever been known by an alternate name?

Yes

Alternate Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Previous Long Term Address

Street Address Address Line 2 City State ZIP Code

Homeless?

I Am Homeless

Last Known Address

Street Address Address Line 2 City State ZIP Code

Contact

In order to process your application we need a way to contact you. Please provide at least one of the following:

Cell Phone Number

Landline Phone Number

Email Address

Cell Phone Number(Required)

Landline Phone Number(Required)

Email Address(Required)

Consent to contact

I consent to be contacted by Hand Up Housing via SMS, email, or phone using the information I provided for the purposes of reviewing my application.

Demographics

Sex(Required)

Other Sex(Required)

Questions

Are you prescribed M.A.T medications e.g (subutex, methadone, etc)?(Required)

How are you paying for your housing fees?(Required)

Are you interested in drug/alcohol treatment?(Required)

Do you have health insurance? If so, please provide info(Required)

Program Details

Are you able to perform household chores?(Required)

Yes

Please provide more details(Required)

Family

Are you in the process of family reunification?

Yes

Please describe(Required)

Personal Contact #1

Contact Name(Required)

First Last

Phone

Relationship

Other Relationship

Can we release information to this person?(Required)

Yes

Is this person an emergency contact?

Yes

Notes

Add an additional contact?

Personal Contact #2

Contact Name(Required)

First Last

Phone

Relationship

Other Relationship

Can we release information to this person?(Required)

Yes

Is this person an emergency contact?

Yes

Notes

Add an additional contact?

Personal Contact #3

Contact Name(Required)

First Last

Phone

Relationship

Other Relationship

Can we release information to this person?(Required)

Yes

Is this person an emergency contact?

Yes

Notes

Add an additional contact?

Personal Contact #4

Contact Name(Required)

First Last

Phone

Relationship

Other Relationship

Can we release information to this person?(Required)

Yes

Is this person an emergency contact?

Yes

Notes

Substance Use History

Drug(s) of Choice(Required)

Amphetamines

Barbiturates

Benzodiazepines

Buprenorphine

Cocaine

Ecstasy (MDMA)

Methadone

Methamphetamine

Morphine

Oxy

PCP

THC

Alcohol

Bath Salts

Kratom

Heroin

Opiates

Ketamine

TCA

Fentanyl

Inhalants

What were the last drugs used and when?(Required)

For how many years have you been using alcohol and/or drugs?(Required)

Medical

Do you have any allergies?(Required)

Yes

Please enter your allergies(Required)

Do you have any physical health/ medical conditions or disabilities?(Required)

Yes

Please describe(Required)

Mental Health

Do you have any mental health issues or diagnosis?(Required)

Yes

Please describe(Required)

Do you have a history of self-harm?(Required)

Yes

Please describe(Required)

Have you ever experienced any suicidal ideations, attempts, or received in-patient treatment for self-harming behaviors?(Required)

Yes

Please describe(Required)

Medications

Are you currently using any prescriptions medications?(Required)

Yes

Prescription Medication #1

Medication Name(Required)

Status

Medication Description

Dosage

Unit Type (eg. mg, g, mL)

Pill Count

Add New Prescription Medication?

Prescription Medication #2

Medication Name(Required)

Status

Medication Description

Dosage

Unit Type (eg. mg, g, mL)

Pill Count

Add New Prescription Medication?

Prescription Medication #3

Medication Name(Required)

Status

Medication Description

Dosage

Unit Type (eg. mg, g, mL)

Pill Count

Add New Prescription Medication?

Prescription Medication #4

Medication Name(Required)

Status

Medication Description

Dosage

Unit Type (eg. mg, g, mL)

Pill Count

Treatment History

Are you currently in a treatment program?(Required)

Yes

Current Treatment Program

Program Name

Program Type

Inpatient

Outpatient

Sober Living

Start Date

MM slash DD slash YYYY

Estimated Discharge Date

MM slash DD slash YYYY

Treatment Counselor Name

Treatment Counselor Number

Are you planning to attend an aftercare program or an intensive outpatient program?

Yes

Please describe

Recovery

What is your Sober or Clean date?(Required)

MM slash DD slash YYYY

Have You Lived In A Recovery Home?(Required)

Yes

Recovery Home Contact

Recovery Home Number

Courts & Criminal Justice

Do you have a Department of Corrections Number?(Required)

Yes

Department of Corrections Number(Required)

Have you ever been charged or convicted of Arson?(Required)

Yes

Please describe(Required)

Have you ever been charged or convicted of a Felony?(Required)

Yes

Please describe(Required)

Have you ever been charged or convicted of any violent crimes in any jurisdiction?(Required)

Yes

Please describe IN DETAIL the events of all the violent crimes. We consider Violent Offenders on a case-by-case basis.(Required)

Restrictions

Are you required to register as a sex offender?

Yes

Please provide the level and any other relevant details(Required)

Select all legal requirements that apply(Required)

None Applicable

House Arrest

Probation

Parole

Drug Court

Other

House Arrest

House Arrest Reference Number

Full Name(Required)

First Last

Phone Number

Email Address

Relationship

Can we release information to this person?(Required)

Yes

Is this person an emergency contact?

Yes

Notes

Probation

Probation Reference Number

Length of Probation

Full Name(Required)

First Last

Phone Number

Email Address

Relationship

Can we release information to this person?(Required)

Yes

Is this person an emergency contact?

Yes

Notes

Parole

Parole Reference Number

Length of Parole

Full Name(Required)

First Last

Phone Number

Email Address

Relationship

Can we release information to this person?(Required)

Yes

Is this person an emergency contact?

Yes

Notes

Drug Court

Drug Court Reference Number

Full Name(Required)

First Last

Phone Number

Email Address

Relationship

Can we release information to this person?(Required)

Yes

Is this person an emergency contact?

Yes

Notes

Other

Please list any other legal requirements

Would you like to add any other legal contacts?

Legal Contact #1

Full Name(Required)

First Last

Phone Number

Email Address

Relationship

Can we release information to this person?(Required)

Yes

Is this person an emergency contact?

Yes

Notes

Add new legal contact?

Legal Contact #2

Full Name(Required)

First Last

Phone Number

Email Address

Relationship

Can we release information to this person?(Required)

Yes

Is this person an emergency contact?

Yes

Notes

Add new legal contact?

Legal Contact #3

Full Name(Required)

First Last

Phone Number

Email Address

Relationship

Can we release information to this person?(Required)

Yes

Is this person an emergency contact?

Yes

Notes

Admissions

When would you like to move in?(Required)

MM slash DD slash YYYY

Do you have a personal relationship with anyone that works for Hand Up Housing or have lived at one of our properties before?(Required)

Yes

Who is it?(Required)

What is the nature of the relationship?(Required)

Client Statement

How did you hear about our program?

Were you referred to Hand Up Housing?

Yes

Please include who referred you

Personal Finance

If for some reasons you cannot pay rent per week/month who can you call upon to help you?(Required)

Transportation

Do you have a valid drivers license?(Required)

Yes

Are you willing to be of service and help other residents get to meetings?

Yes

What is your primary mode of transportation?(Required)

Personal Vehicle

Family/ Friend

Public Transit

Do you have proof or registration?

Yes

Do you have proof of insurance?

Yes

Do you plan on having your personal vehicle at the property?(Required)

Yes

Vehicle Details

Make(Required)

Model(Required)

Color(Required)

License Plate Number(Required)

Sensitive Information

Drivers License Number

State ID Number

Social Security Number

Additional Info

Please enter any other information about yourself or your situation that you feel we need to know(Required)

Application

Fill Out the Application Below

Personal Details

Contact

Demographics

Questions

Program Details

Family

Personal Contact #1

Personal Contact #2

Personal Contact #3

Personal Contact #4

Substance Use History

Medical

Mental Health

Medications

Prescription Medication #1

Prescription Medication #2

Prescription Medication #3

Prescription Medication #4

Treatment History

Current Treatment Program

Recovery

Courts & Criminal Justice

Restrictions

House Arrest

Probation

Parole

Drug Court

Other

Legal Contact #1

Legal Contact #2

Legal Contact #3

Admissions

Client Statement

Personal Finance

Transportation

Vehicle Details

Sensitive Information

Additional Info

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