Traditional Housing/Residential Program Application

Applicant Name *

Birthdate *

Age *

Current Address *

City *

Zip *

Are you coming from another shelter? *

Yes

Are you coming from a correctional facility? *

Yes

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

Are you currently involved with DCS? *

Yes

Do you have children under the age of 18 who may be visiting you at Hope Alive? *

Yes

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

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

Name of school you attend *

Are you currently employed? *

Yes

who is your current employer? *

Date this employment began *

Is this job through a temp agency? *

Yes

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

If yes, for what reason? *

Have you ever received government assistance for housing? *

Yes

Are you currently living in a shelter? *

Yes

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 *

Address 1 out in date *

Reason for leaving *

Address 2 *

Address 2 move in date *

Address 2 out in date *

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

Physical Health History

How would you rate your overall health at present? *

Poor

Fair

Good

Excellent

Are you disabled? *

Yes

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

If YES, please describe *

Have you ever been hospitalized for a mental health related issue? *

Yes

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

Please describe *

Do you currently drink alcohol? *

Yes

Do you currently use drugs/pills? *

Yes

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

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