Recovery Residence Housing Application

"*" indicates required fields

Applicants are reviewed for program eligibility requirements including; Treatment participation, homelessness, family composition, level of income, and disability status. Person (‘s) meeting our program eligibility requirements are not discriminated against based on race, religion, age, familial status, disability, national origin, sex, or any other arbitrary basis. Requests for reasonable accommodations are made at intake.

I hereby acknowledge that the information below is true and correct. I am aware that falsification of this application and/or withholding information may be grounds for non-acceptance into the program and /or program termination. This information is confidential and shall be used for determining program eligibility as well as to identify applicant goals.

Signature*

Date*

Personal Information

Name

First Last

Age:*

DOB*

Address*

Street Address City State ZIP Code

Best Contact Phone*

Alternate Contact Phone

Do we have permission to leave a message on the phone numbers listed above, regarding your housing application?*

Yes

Program Application

True North Recovery Follow’s Federal Fair Housing and Equal Opportunity Laws. We do not discriminate against any person based on race, color, religion, age, familial status, disability, national origin, sex, or any other arbitrary basis. Applicants are reviewed for program eligibility requirements including; homelessness, family composition, and disability status.

Persons meeting our program eligibility requirements are not discriminated against based on race, color, religion, age, familial status, disability, national origin, sex, or any other arbitrary basis. Applicants and referrals for our supportive housing program are acquired through targeted outreach with other social service agencies, community organizations, and treatment providers.

Please take your time to complete this narrative and application as completely as possible (each adult must complete this part). In order for your application to be considered, all questions must be answered completely and honestly to the best of your ability.

Please describe what issues led you to seek housing with True North Recovery. Be specific as to details such as how, when, where and your personal responsibility. Please use additional sheets if necessary.

Explain Here*

1. Where did you stay last night?*

2. Who referred you to True North Recovery?*

3. Please check a box that applies to where you stayed last night:*

Emergency Shelter

Substance abuse program

Apartment or house

Hospital (non-psychiatric)

Staying or living in apartment or house / family members home friends home.

Facility/ Jail or prison Hotel/Motel

Place not meant for habitation (the streets, a vehicle, an abandoned building).

Transitional Shelter building, anywhere outside, etc.)

4. How long have you been in this place?*

One week or less

More than one week

Less than one month

One-three months

More than three months

One year or longer

5. Have you previously applied to True North Recovery housing?*

Yes

If Yes When?*

6. Do you have a personal relationship with anyone that works for True North Recovery?*

Yes

If Yes Who?*

7. Do you have a valid Driver’s License/State ID Card?*

Yes

Drivers License ID #

State*

State

Exp. Date*

8. Are you currently employed?*

Yes

If so, who is your employer?

If so, how long have you been employed?

If so, how many hours did you work last week?

If so, is this permanent, temporary, or seasonal work?

If unemployed, are you currently seeking employment?

9. Please List all sources of income include cash assistance and food stamps.*

10. Do you have a physical disability?*

Yes

No If so, what is the nature of the disability?*

11. Do you have a mental health diagnosis?*

Yes

If so, what is your diagnosis and the name and location of the provider that diagnosed you?*

12. Do you think you have a need for mental health services?*

Yes

If so, please describe your needs:*

13. Are you currently using any over-the-counter medication?*

Yes

If yes list medication:*

14. Are you currently on ANY prescribed medication?*

Yes

If so please list the medication and the reason you were prescribed it*

15. Do you drink alcohol?*

Yes

If so, how often?*

16. Have you ever drank alcohol?*

Yes

17. When did you drink your last alcoholic beverage?*

18. Do you use tobacco?*

Yes

If so, how often?*

19. Have you ever used drugs?*

Yes

What drugs have you used?*

When was the last time you used drugs?*

What drug(s) did you last use?*

20. Are you willing to be alcohol/drug tested?*

Yes

21. Have you ever been enrolled in a drug rehab or treatment program?*

Yes

Name of Program 1:*

Location:*

Date:*

How long:*

Did you complete the program?*

Yes

Name of Program 2:*

Location:*

Date:*

How long:*

Did you complete the program?*

Yes

22. Have you ever been arrested or convicted of a crime?*

Yes

If so please explain:*

23. Have you ever been convicted of arson?*

Yes

24. Have you ever been convicted of a sex crime?*

Yes

If Yes are you a registered sex offender?*

Yes

25. Are you currently on probation or parole?*

Yes

If yes, for what charge and who is your probation officer?*

26. Do you currently have a restraining order?*

Yes

If yes, who is the restrained person?*

Expiration Date:*

27. Are you fleeing a domestic violence situation?*

Yes

28. Do you need referral to domestic violence services?*

Yes

29. Do you currently have an open case with Children’s Services?*

Yes

If yes, please explain, and provide your case worker name and number.*

30. Do you have legal custody of your children? (Legal custody means you have been to court and have paperwork).*

Yes

31. Do have any court ordered treatment requirements?*

Yes

If yes, are you currently seeking treatment for this requirement?*

Yes

If yes, who are you currently attending treatment with to adhere to this requirement?*

32. Do you have any ASAP requirements?*

Yes

If yes, are you currently seeking treatment for this requirement?*

Yes

If no, who are you currently attending treatment with to adhere to this requirement?*

Acknowledgements

Dear Applicant,
Thank you for your interest in True North Recovery transition recovery housing. True North Recovery has 15 beds for men and 8 women’s beds, where residents may stay and participate in the program for up to six months. The Recovery housing of True North Recovery is a program. Residents are required to participate in all groups and workshops as scheduled in their treatment plan. You will not be turned away if you are indigent. Staff conducts random drug testing on residents as True North Recovery has a no drugs or alcohol policy. There is also zero tolerance for violence or threats of violence towards anyone. It is important that all applicants understand these aspects of the program before applying.

Initial the follow statements that you understand:

Completing this application does not guarantee that you will be accepted into Housing. If you do not have a current telephone number listed, we will be unable to contact you. It is your responsibility to alert us to any change in your contact information. All housing applications are reviewed by the housing manager and treatment team prior to being contacted for an interview. All applicant must either be in out-patient treatment or in the process of entering an out-patient program. If you are selected for an Interview, you will receive a telephone call. You may check the status of your application daily. If we do not here from you within a month of applying, we will assume you no longer in need of housing and your name will be removed from the list. It is your responsibility to alert us to any change in your contact information. Thank you for your interest in True North Recovery Housing. We look forward to reviewing your application as soon as possible.

My signature below certifies that all information on this application is true and contains no willful falsifications or misrepresentations. All information provided is used by the True North Recovery to determine eligibility and is kept confidential.

By signing below, I authorize True North Recovery to contact those listed on my application in order to obtain information deemed appropriate to consider my application for the True North Recovery transitional living housing.

Signature*

Date*

Type Your Name

First Last

Are You Human? Answer This: 2+5=?*