Traditional Housing/Residential Program Application Leave this field blank Applicant Name * Birthdate * Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 Age * Current Address * City * Zip * Are you coming from another shelter? * Yes No Are you coming from a correctional facility? * Yes No If Yes to Either questions above, please name Shelter/facility * Expected Release/Discharge Date (optional) Phone Number * Alternate Phone Number (optional) May we leave a message at either number? * Yes Voicemail Yes other person Yes Text Message No Messages Email (optional) Referred to Hope Alive By * Family **Though Hope Alive does not allow children to live in our apartments, we want to understand your family.** How many children do you have? * What are their ages? (optional) Child One Age (optional) Child Two Age (optional) Child Three Age (optional) Child Four Age (optional) Are you currently working to reunify with your children? * Yes No Are you currently involved with DCS? * Yes No Do you have children under the age of 18 who may be visiting you at Hope Alive? * Yes No If YES, please list an emergency contact for your children (optional) Emergency Contact name * Relationship to this person * Phone Number for Emergency Contact * Please describe your reason for applying to Hope Alive * What would you like to accomplish while living at Hope Alive? * Race/Ethnic Background What is your race/ethnicity? * White Asian American Black/African American Native Hawaiian/Pacific Islander Hispanic/Latino American Indian/Alaskan Native Multiracial International Is your primary language something other than English? * Yes No What is your primary language? * Education & Occupation Information Please indicate your educational level * Less than high school H.S. equivalent/GED High School Diploma Vocational Some College (no degree completed) Bachelor’s Degree Master’s Degree Doctoral Degree Other Are you currently in school? * Yes No Name of school you attend * Are you currently employed? * Yes No who is your current employer? * Date this employment began * Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 Is this job through a temp agency? * Yes No Hours worked per week * If NOT employed, what is your income source? * Monthly Amount * If NOT employed, how long have you been unemployed? * Housing History Have you ever been evicted? * Yes No If yes, for what reason? * Have you ever received government assistance for housing? * Yes No Are you currently living in a shelter? * Yes No Case Worker Name * Case Worker Phone # * **Please note, we will require a release to coordinate with your caseworker. (optional) Please list your last 2 residences, other than your current address, starting with the most recent (optional) Address 1 * Address 1 move in date * Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 Address 1 out in date * Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 Reason for leaving * Address 2 * Address 2 move in date * Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 Address 2 out in date * Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 Legal Background(Check as many as apply) * No legal history Arrest(s) non-substance related Arrest(s) substance related Currently on probation Currently on parole Court ordered treatment Jail/prison time served Drug Court Currently on home detention Please describe the most recent legal issue * List and describe any conviction(s), date of conviction(s), and any pending charges * In the past year, were you a victim of any violent crimes such as assault, rape, or domestic violence? * Yes No Physical Health History How would you rate your overall health at present? * Poor Fair Good Excellent Are you disabled? * Yes No Please describe your disability * Please list any medications you are currently taking and the condition they treat: * Mental Health History Have you ever received treatment for, or been diagnosed with, a mental illness? * Yes No If YES, please describe * Have you ever been hospitalized for a mental health related issue? * Yes No please provide the name of your therapist/care provider * Counselor/Care Provider Phone Number: (optional) **Please note, we will require a release to coordinate with your current counselor/care provider. Do you have a history of substance or alcohol abuse? * Yes No Please describe * Do you currently drink alcohol? * Yes No Do you currently use drugs/pills? * Yes No When was the last time you used an illegal substance, misused prescription drugs, or drank alcohol? * I understand that, due to the nature of a transitional living program with the goal of aiding women to become self-sufficient, I acknowledge that I am physically and emotionally capable of doing all household and yard chores. I understand that if at some point I become unable or unwilling to do these chores I will be required to leave this program. I understand that I am going to be given a drug and alcohol screening prior to being admitted to Hope Alive’s Residential Program. I also certify that the above information is true and accurate to the best of my knowledge. I understand that falsified information may be cause for my dismissal from Hope Alive’s program. Signature * Please Type you full name. This will server as your signature Date * Today's Date Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 Hope Alive Resident Expectations (optional) CONDUCT Absolutely no drug, alcohol or prescription narcotics (even if prescribed by your physician) are allowed on premises – you MUST provide a NEGATIVE urine/breathalyzer at any time. Absolutely no weapons of any kind are allowed on the premises. Violence or threats of violence will not be tolerated. Be respectful and courteous to each other, staff, and neighbors. Stealing will not be tolerated. MAINTENANCE Part of transitional housing is learning responsible property maintenance and upkeep, including yard work, snow removal, leaf removal, and overall upkeep of the yard. Therefore, ALL RESIDENTS are required to share in the responsibility of these tasks. Yard work will be assigned on a rotating basis, and all residents will be expected to take turns with each task, including mowing. Residents are expected to keep their rooms and common areas clean, including taking part in dish washing, trash removal, and other household chores. PERSONAL PROPERTY ALL personal property must be kept in an orderly fashion. Make sure you comply with space and storage rules (no moving furniture in or out etc.). All rooms, your person, and your vehicle are subject to inspection at any time. Upon check-out, all personal property must be taken with you. Anything left behind will be discarded. No personal furniture is allowed to be brought into the apartment or personal rooms at any time. Small flat-screen TVs are allowed. GENERAL To maintain cleanliness of Hope Alive, when moving in, all personal items will be placed in a “bug zapper.” Rent is due by the 3rd of each month. All accrued rent charges are required to be paid, including any remaining balance, upon exit from Hope Alive. Residents must attend 2 groups, case management, and counseling weekly and must be on time. Supervised urine drug screens and breathalyzers will be administered upon interview, at admission, and at random throughout your stay at Hope Alive. Smoking and vaping are discouraged but allowed in the designated area only. No smoking or using tobacco products (including vaping and e-cigarettes) is allowed in apartments. To spend a night away from Hope Alive, residents must have been at Hope Alive at least 2 weeks, be working at least 15 hours, and request approval via Overnight Pass Request. Please note: residents on a problem-solving court (drug court, mental health court, hope probation, etc.) must gain approval through the court first. Residents that are not working at least 15 hours per week are required to participate in work study at Hope Alive. Residents are expected to take medication as prescribed. Remember, confidentiality is a MUST. Pets are prohibited. Residents must supply their own toiletries, paper products (including toilet paper, paper towels, etc.), cleaning supplies, laundry products, etc. Everyone is to contribute her fair share. If you need help with this, please see the office. Curfew hours are Sunday-Thursday at 10pm and Friday and Saturday at 11pm. Quiet time is 9:00pm-10:00am. Visitors, including residents from other apartments, are not permitted during this time. Anyone choosing not to fulfill their responsibilities to Hope Alive, or not complying with these expectations will be asked to leave Hope Alive. By signing below, I, a potential or admitted resident of Hope Alive, acknowledge that I have read and understood all the above expectations and am willing, able, and agree to abide by them. I understand that failure to abide by these expectations may result in my being asked to leave Hope Alive. Signature * Please Type you full name. This will server as your signature Date * Today's Date Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 Review Inputs