Transitional Housing Application

  • Contact Information

  • A representative may be social worker, case manager, outreach worker, or other health care professional.
  • A representative may be social worker, case manager, outreach worker, or other health care professional.
  • A representative may be social worker, case manager, outreach worker, or other health care professional.

  • Personal Information

  • This is the amount of money you earn each month after tax is taken off. This can be a combination of many sources of income.
  • Check all that apply.
  • Please include the name of medication, purpose of use, and frequency of use. You may add additional comments you feel would be helpful to note.

  • Drug History

  • Please note the term "Drug" includes the following:

    - Illicit street drugs

    - Designer drugs

    - Marijuana

    - Alcohol

    - Misuse of prescription drugs

  • Please check all that apply.
  • Please include the name of program, location, and duration. You may add additional comments you feel would be helpful to note.

  • Recovery Goals

  • Please include as much detail as possible.
  • Please include as much detail as possible.
  • Please include as much detail as possible.
  • Please include as much detail as possible.