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Home
Services
Permanent / Transitional Rental Form
Company
News
Success Stories
Help
Contact us
Courses
+1
(907) 333-2468
Sign in
Contact Us
Below you will find some questions that help us learn a bit about you so we can determine how we can help.
Personal Details
First Name
Middle Name
Last Name
Have you ever been known by an alternate name?
Yes
No
Alternate Name
Date of Birth
Contact Details
We use the Cell Phone Number & Email below to text or email you the full application form.
Please provide at least one of the following Contact Details:
Cell Phone Number
Yes
Cell Phone Number
Landline Phone Number
Yes
Landline Phone Number
Email Address
Yes
Email Address
Consent to contact
I consent to be contacted by House of Transformation via SMS, email, or phone using the information I provided for the purposes of reviewing my application.
Demographics
Sex
Male
Female
Decline to respond
Other
Gender Identity
Male
Female
Transgender Male / Transman / FTM
Transgender Female / Transwoman / MTF
Gender Queer
Decline to respond
Other
Ethnicity
Decline to respond
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
What is the highest level of education you completed?
Elementary or High school, no diploma
Elementary or High school, GED
High school diploma
College, no degree
Associate's degree, vocational
Associate's degree, academic
Bachelor's degree
Master's degree
Professional degree
Doctorate degree
Female
What is your primary language?
English
Spanish or Spanish Creole
French (including Patois, Cajun)
French Creole
Italian
Portuguese or Portuguese Creole
German
Yiddish
Other West Germanic languages
Scandinavian languages
Greek
Russian
Polish
Serbo-Croatian
Other Slavic languages
Armenian
Persian
Gujarathi
Hindi
Urdu
Other Indic languages
Other Indo-European languages
Chinese
Japanese
Korean
Mon-Khmer, Cambodian
Hmong
Thai
Laotian
Vietnamese
Other Asian languages
Tagalog
Other Pacific Island languages
Navajo
Other Native North American languages
Hungarian
Arabic
Hebrew
African languages
Other
Are you a veteran?
Yes
No
Questions
Are you affiliated with and/or have shares in a Native Corporation?
Program Cost
Transitional Housing beds are $25 to $37/day depending on intake criteria (you will be notified of your daily rate upon approval / acceptance into program).
How will you pay for the program? *
I will pay myself
Someone else will pay
Insurance will pay
I need financial assistance
Other
Financial Assistance
Please describe your financial situation:
Other Payment Method
Please describe how you would like to pay for the program
Insurance Details
Are you the policy holder?
Yes
No
Insurance Company Name
Please enter the exact company name from your insurance card.
Plan Name
Insurance Group ID
Insurance Member ID
Card Issued Date
Claims Phone Number (Insurance Line)
Private Payer Details
First Name
Last Name
Phone Number
Email Address
Relationship
Friend
Mother
Father
Brother
Sister
Child
Grandfather
Grandmother
Aunt
Uncle
Niece
Nephew
Cousin
Relative
Sponsor
Case Manager
Recovery Coach
Medical Doctor (PCP)
Medication-Assisted-Treatment Doctor (MAT)
Psychiatrist
Psychologist
Therapist
Nutritionist
Employer
Employee-Assistance-Program Contact
Union Representative
Probation Officer
Parole Officer
House Arrest Contact
Drug Court Contact
Social Services Case Worker
Domestic Violence Case Worker
Attorney
Legal Contact
Other
Can we release information to this person?
Yes
No
Is this person an emergency contact?
Yes
No
Notes
How will you pay for the program? *
What is the likely preferred payment method? (can be changed later)
Credit/Card
Cash
Check
Money Order
Bank Account(ACH)
Write-Off
Venmo
Zelle
Other
Other Payment Method
Program Details
Do you have any concerns with sharing a room?
Yes
No
Please describe your concerns
Are you able to perform household chores?
Yes
No
Please describe your concerns
Personal Contacts (Family)
What is your marital status?
Single
Married
Engaged
Separated
Domestic Partnered
Widowed
Are you fleeing a domestic violence situation?
Yes
No
Please describe your situation
Have you notified the authorities about your domestic violence situation?
Yes
No
Domestic Violence Case Reference Number
Domestic Violence Case Worker
First Name
Last Name
Phone Number
Email Address
Relationship
Friend
Mother
Father
Brother
Sister
Child
Grandfather
Grandmother
Aunt
Uncle
Niece
Nephew
Cousin
Relative
Sponsor
Case Manager
Recovery Coach
Medical Doctor (PCP)
Medication-Assisted-Treatment Doctor (MAT)
Psychiatrist
Psychologist
Therapist
Nutritionist
Employer
Employee-Assistance-Program Contact
Union Representative
Probation Officer
Parole Officer
House Arrest Contact
Drug Court Contact
Social Services Case Worker
Domestic Violence Case Worker
Attorney
Legal Contact
Other
Can we release information to this person?
Yes
No
Is this person an emergency contact?
Yes
No
Notes
Do you need assistance notifying the authorities?
Yes
No
Please provide any other details that might be helpful
Are you in the process of family reunification?
Yes
No
Please Describe
Do you have children?
Yes
No
Please describe your situation
i.e. how many children, their ages, etc
Do you have legal custody of your children?
Yes
No
Do you currently have an open case with Children’s Services?
Yes
No
Please describe the situation
Children’s Services Case Reference Number
Social Services Case Worker
First Name
Last Name
Phone Number
Email Address
Relationship
Friend
Mother
Father
Brother
Sister
Child
Grandfather
Grandmother
Aunt
Uncle
Niece
Nephew
Cousin
Relative
Sponsor
Case Manager
Recovery Coach
Medical Doctor (PCP)
Medication-Assisted-Treatment Doctor (MAT)
Psychiatrist
Psychologist
Therapist
Nutritionist
Employer
Employee-Assistance-Program Contact
Union Representative
Probation Officer
Parole Officer
House Arrest Contact
Drug Court Contact
Social Services Case Worker
Domestic Violence Case Worker
Attorney
Legal Contact
Other
Can we release information to this person?
Yes
No
Is this person an emergency contact?
Yes
No
Notes
Do you have a child support obligation?
Yes
No
How much per month? ($)
Do you need childcare assistance while in treatment or at a SLE?
Yes
No
Please Describe
Substance Use History
Drug(s) of Choice
Methadone
Kratom
K2
Methamphetamine
Morphine
Heroin
Ketamine
Cocaine
Nicotine
Psychedelics
PCP
Alcohol
Buprenorphine
Benzodiazepines
THC
TCA
Barbiturates
Inhalants
Amphetamines
Ecstasy (MDMA)
Bath Salts
Oxy
Fentanyl
Opiates
What were the last drugs used and when?
For how many years have you been using alcohol and/or drugs?
Do you use tobacco?
Yes
No
Would you like to quit using tobacco?
Yes
No
Do you need help with quitting?
Yes
No
Medical
Do you have any allergies?
Yes
No
Please Describe
Do you have any physical health / medical conditions or disabilities?
Yes
No
Please describe your medical conditions or disabilities
Do you have any upcoming appointments or ongoing physical needs?
Yes
No
Please Describe
Mental Health
Do you have any mental health issues or diagnosis?
Yes
No
Please Describe
Have you ever experienced any suicidal ideations, attempts, or received in-patient treatment for self-harming behaviors?
Yes
No
Please Describe
Have you had any suicidal ideation in the past week?
Yes
No
Do you have an Eating Disorder or Body Image Disorder?
Yes
No
Please Describe
Do you have a need for mental health services?
Yes
No
Please Describe
Have you ever been a victim of sex trafficking?
Yes
No
Please provide details
Addictive Behavior
Do you identify patterns in other areas of your life that may have some addictive qualities?
Yes
No
Addictive Qualities
Money
Sex
Relationships
Internet
Food
Shopping
With other addictive qualities
Yes
No
Please list other areas
Communicable Diseases
Are you at risk for exposure to any communicable diseases, or have you been in contact with someone who has?
Yes
No
Please describe
Are you experiencing shortness of breath, coughing, fever, or other symptoms of Coronavirus and/or a flu?
Yes
No
Have you been tested for the Coronavirus?
Yes
No
What was the result of your Coronavirus test?
Positive
Negative
I havent received the result yet
Are you willing to be tested for the Coronavirus?
Yes
No
Please describe the reason for refusing the Coronavirus test
Have you traveled outside of the country in the last 30 days?
Yes
No
Please list the travel locations
Medications
Are you currently using any prescription medications?
Yes
No
Prescription Medication #
1
Status
Active
Inactive
Medication Description
Medical
Psychiatric
Taper
Palliatives
MAT (Vivitrol, Suboxone, etc)
Vaccine
Name
Dosage
Unit Type (eg. mg, g, mL)
Quantity
Start / End Date Unknown
Yes
No
Start Date
End Date
Add New Prescription Medication
Are you currently using any over-the-counter medication?
Yes
No
OTC Medication #
1
Status
Active
Inactive
Medication Description
Medical
Psychiatric
Taper
Palliatives
MAT (Vivitrol, Suboxone, etc)
Vaccine
Name
Dosage
Unit Type (eg. mg, g, mL)
Quantity
Start Date
End Date
Add New OTC Medication
Are you participating in or about to enter any drug replacement program?
Yes
No
Please select all applicable drug replacement programs:
Vivitrol and ReVia (Naltrexone)
Vivitrol and ReVia – please provide more details
Include frequency of visits, dosage, length of prescription and any other relevant information; also, please list this in the Prescription Medication section as well
Narcan (Naloxone)
Narcan – please provide more details
Include frequency of visits, dosage, length of prescription and any other relevant information; also, please list this in the Prescription Medication section as well
Subutex (Buprenophine)
Subutex – please provide more details
Include frequency of visits, dosage, length of prescription and any other relevant information; also, please list this in the Prescription Medication section as well
Campral (Acamprosate)
Campral – please provide more details
Include frequency of visits, dosage, length of prescription and any other relevant information; also, please list this in the Prescription Medication section as well
Baclofen (Lioresal)
Baclofen – please provide more details
Include frequency of visits, dosage, length of prescription and any other relevant information; also, please list this in the Prescription Medication section as well
Methadone (Methadose & Dolophine)
Methadone – please provide more details
Include frequency of visits, dosage, length of prescription and any other relevant information; also, please list this in the Prescription Medication section as well
Suboxone (Buprenophine)
Suboxone – please provide more details
Include frequency of visits, dosage, length of prescription and any other relevant information; also, please list this in the Prescription Medication section as well
Antabuse (Disulfiram)
Antabuse – please provide more details
Include frequency of visits, dosage, length of prescription and any other relevant information; also, please list this in the Prescription Medication section as well
Topamax (Topiramate)
Topamax – please provide more details
Include frequency of visits, dosage, length of prescription and any other relevant information; also, please list this in the Prescription Medication section as well
Sublocade (Buprenophine)
Sublocade – please provide more details
Include frequency of visits, dosage, length of prescription and any other relevant information; also, please list this in the Prescription Medication section as well
Other
Other – please provide more details
Include frequency of visits, dosage, length of prescription and any other relevant information; also, please list this in the Prescription Medication section as well
Mat Doctor
First Name
Last Name
Phone Number
Email Address
Relationship
Friend
Mother
Father
Brother
Sister
Child
Grandfather
Grandmother
Aunt
Uncle
Niece
Nephew
Cousin
Relative
Sponsor
Case Manager
Recovery Coach
Medical Doctor (PCP)
Medication-Assisted-Treatment Doctor (MAT)
Psychiatrist
Psychologist
Therapist
Nutritionist
Employer
Employee-Assistance-Program Contact
Union Representative
Probation Officer
Parole Officer
House Arrest Contact
Drug Court Contact
Social Services Case Worker
Domestic Violence Case Worker
Attorney
Legal Contact
Other
Can we release information to this person?
Yes
No
Is this person an emergency contact?
Yes
No
Notes
Treatment History
Are you currently in a treatment program?
Yes
No
Are you willing to enter a treatment program?
Yes
No
Why not?
Do you need assistance?
Yes
No
Please Describe
Current Treatment Program #
1
Program Name
Program Type
Inpatient
Outpatient
Sober Living
Start Date
Estimated Discharge Date
Are you planning to attend an aftercare program or an intensive outpatient program?
Yes
No
Please Describe
Add New Treatment Program
Have you ever been through any other treatment programs previously?
Yes
No
Programs range from inpatient hospital detox or residential programs, to outpatient treatment centers and sober living homes
Treatment Program #
1
Please list your previous treatment programs starting with the most recent one
Program Name
Program Type
Inpatient
Outpatient
Sober Living
Please list your previous treatment programs starting with the most recent one
Approximate Start Date
Approximate Length of Stay
Did you successfully complete the program?
Yes
No
How were you discharged?
I was discharged against medical advice (AMA)
Left the program without notification (AWOL)
Facility decided discharge (Therapeutic Discharge)
Length of Abstinence After Treatment (Days)
Add New Treatment Program
Recovery
What is your Sober or Clean date?
Do you have a Sponsor?
Yes
No
Sponsor Details
First Name
Last Name
Phone Number
Email Address
Relationship
Friend
Mother
Father
Brother
Sister
Child
Grandfather
Grandmother
Aunt
Uncle
Niece
Nephew
Cousin
Relative
Sponsor
Case Manager
Recovery Coach
Medical Doctor (PCP)
Medication-Assisted-Treatment Doctor (MAT)
Psychiatrist
Psychologist
Therapist
Nutritionist
Employer
Employee-Assistance-Program Contact
Union Representative
Probation Officer
Parole Officer
House Arrest Contact
Drug Court Contact
Social Services Case Worker
Domestic Violence Case Worker
Attorney
Legal Contact
Other
Can we release information to this person?
Yes
No
Is this person an emergency contact?
Yes
No
Notes
Assistance and Help
Do you have a learning disability or difficulty reading?
Yes
No
Please describe
Do you have any immediate needs such as clothing or toiletries?
Yes
No
Please describe *
Do you need help to renew any forms of identification?
Yes
No
Please describe *
Do you need assistance with any food programs?
Yes
No
Please describe *
Food programs assistance - select all that apply:
Food Stamps (SNAP)
Women, Infants, and Children Program (WIC)
Electronic Benefits Transfer Card (EBT)
Food Pantry
Courts and Criminal Justice
Are you currently involved in any legal proceedings or criminal justice issues?
Yes
No
Please describe and add any upcoming court dates
Do you have a requirement for Community Service?
Yes
No
Please describe
Do have any court ordered treatment requirements?
Yes
No
Are you currently seeking treatment for this requirement or have you found a treatment program to adhere to this requirement?
Yes
No
Please provide more details
Do you have any pending sentencing or possible jail time upcoming?
Yes
No
When?
Please describe
Have you ever been charged or convicted of a Felony?
Yes
No
Please describe
Have you ever been charged or convicted of abuse or neglect of any person, including but not limited to disabled person, senior, or child?
Yes
No
Please describe
Are you affiliated with any gang?
Yes
No
Please describe
Restrictions
Select all legal requirements that apply
None Applicable
Yes
No
House Arrest
Probation
Parole
Drug Court
Other
Please list any other legal requirements
House Arrest Reference Number
House Arrest Contact
First Name
Last Name
Phone Number
Email Address
Relationship
Friend
Mother
Father
Brother
Sister
Child
Grandfather
Grandmother
Aunt
Uncle
Niece
Nephew
Cousin
Relative
Sponsor
Case Manager
Recovery Coach
Medical Doctor (PCP)
Medication-Assisted-Treatment Doctor (MAT)
Psychiatrist
Psychologist
Therapist
Nutritionist
Employer
Employee-Assistance-Program Contact
Union Representative
Probation Officer
Parole Officer
House Arrest Contact
Drug Court Contact
Social Services Case Worker
Domestic Violence Case Worker
Attorney
Legal Contact
Other
Can we release information to this person?
Yes
No
Is this person an emergency contact?
Yes
No
Notes
Probation Reference Number
Length of Probation
Probation Officer
First Name
Last Name
Phone Number
Email Address
Relationship
Friend
Mother
Father
Brother
Sister
Child
Grandfather
Grandmother
Aunt
Uncle
Niece
Nephew
Cousin
Relative
Sponsor
Case Manager
Recovery Coach
Medical Doctor (PCP)
Medication-Assisted-Treatment Doctor (MAT)
Psychiatrist
Psychologist
Therapist
Nutritionist
Employer
Employee-Assistance-Program Contact
Union Representative
Probation Officer
Parole Officer
House Arrest Contact
Drug Court Contact
Social Services Case Worker
Domestic Violence Case Worker
Attorney
Legal Contact
Other
Can we release information to this person?
Yes
No
Is this person an emergency contact?
Yes
No
Notes
Parole Reference Number
Length of Parole
Parole Officer
First Name
Last Name
Phone Number
Email Address
Relationship
Friend
Mother
Father
Brother
Sister
Child
Grandfather
Grandmother
Aunt
Uncle
Niece
Nephew
Cousin
Relative
Sponsor
Case Manager
Recovery Coach
Medical Doctor (PCP)
Medication-Assisted-Treatment Doctor (MAT)
Psychiatrist
Psychologist
Therapist
Nutritionist
Employer
Employee-Assistance-Program Contact
Union Representative
Probation Officer
Parole Officer
House Arrest Contact
Drug Court Contact
Social Services Case Worker
Domestic Violence Case Worker
Attorney
Legal Contact
Other
Can we release information to this person?
Yes
No
Is this person an emergency contact?
Yes
No
Notes
Drug Court Reference Number
Drug Court Contact
First Name
Last Name
Phone Number
Email Address
Relationship
Friend
Mother
Father
Brother
Sister
Child
Grandfather
Grandmother
Aunt
Uncle
Niece
Nephew
Cousin
Relative
Sponsor
Case Manager
Recovery Coach
Medical Doctor (PCP)
Medication-Assisted-Treatment Doctor (MAT)
Psychiatrist
Psychologist
Therapist
Nutritionist
Employer
Employee-Assistance-Program Contact
Union Representative
Probation Officer
Parole Officer
House Arrest Contact
Drug Court Contact
Social Services Case Worker
Domestic Violence Case Worker
Attorney
Legal Contact
Other
Can we release information to this person?
Yes
No
Is this person an emergency contact?
Yes
No
Notes
Are you required to register as a sex offender?
Yes
No
Please provide the level and any other relevant details
Are there any Restraining Orders against you or by you?
Yes
No
Please describe the restraining order situation including who it is, your relationship, relevant dates
Admissions
When would you like to move in?
Do you have a personal relationship with anyone that works for House of Transformation?
Yes
No
Who is it?
What is the nature of the relationship?
Are there any issues that could prevent you from completing the program?
Yes
No
Please provide details
Client Statement
Were you referred to House of Transformation?
Yes
No
Please include who referred you
Please describe what issues led you to seek housing with House of Transformation. Be specific as to details such as how, when, where and your personal responsibility.
What are your goals and expectations?
Employment
Are you able to work?
Yes
No
Please Describe
Are you currently employed?
Yes
No
What is the companys name?
Employer Contact Details
First Name
Last Name
Phone Number
Email Address
Relationship
Friend
Mother
Father
Brother
Sister
Child
Grandfather
Grandmother
Aunt
Uncle
Niece
Nephew
Cousin
Relative
Sponsor
Case Manager
Recovery Coach
Medical Doctor (PCP)
Medication-Assisted-Treatment Doctor (MAT)
Psychiatrist
Psychologist
Therapist
Nutritionist
Employer
Employee-Assistance-Program Contact
Union Representative
Probation Officer
Parole Officer
House Arrest Contact
Drug Court Contact
Social Services Case Worker
Domestic Violence Case Worker
Attorney
Legal Contact
Other
Can we release information to this person?
Yes
No
Is this person an emergency contact?
Yes
No
Notes
Are you currently seeking employment?
Yes
No
Are you willing to complete a minimum of two job applications a day?
Yes
No
Do you have any skills or industry experience that would assist you in finding a job?
Yes
No
Please Describe
Is this permanent, temporary, or seasonal work?
Permanent
Temporary
Seasonal
How long have you been employed there?
How many hours do you typically work per week?
What is your work schedule?
Do you have an Employee Assistance Program (EAP)?
Yes
No
EA Contact
First Name
Last Name
Phone Number
Email Address
Relationship
Friend
Mother
Father
Brother
Sister
Child
Grandfather
Grandmother
Aunt
Uncle
Niece
Nephew
Cousin
Relative
Sponsor
Case Manager
Recovery Coach
Medical Doctor (PCP)
Medication-Assisted-Treatment Doctor (MAT)
Psychiatrist
Psychologist
Therapist
Nutritionist
Employer
Employee-Assistance-Program Contact
Union Representative
Probation Officer
Parole Officer
House Arrest Contact
Drug Court Contact
Social Services Case Worker
Domestic Violence Case Worker
Attorney
Legal Contact
Other
Can we release information to this person?
Yes
No
Is this person an emergency contact?
Yes
No
Notes
Are you a member of a Union?
Yes
No
Union Name
Union Representative
First Name
Last Name
Phone Number
Email Address
Relationship
Friend
Mother
Father
Brother
Sister
Child
Grandfather
Grandmother
Aunt
Uncle
Niece
Nephew
Cousin
Relative
Sponsor
Case Manager
Recovery Coach
Medical Doctor (PCP)
Medication-Assisted-Treatment Doctor (MAT)
Psychiatrist
Psychologist
Therapist
Nutritionist
Employer
Employee-Assistance-Program Contact
Union Representative
Probation Officer
Parole Officer
House Arrest Contact
Drug Court Contact
Social Services Case Worker
Domestic Violence Case Worker
Attorney
Legal Contact
Other
Can we release information to this person?
Yes
No
Is this person an emergency contact?
Yes
No
Notes
Does your employer know you are in treatment?
Yes
No
Are you willing to work 40 hours a week of gainful employment?
Yes
No
Personal Finance
If for some reason you cannot pay rent per week / month who can you call upon to help you?
Do you receive any ongoing financial reimbursement for any reason?
Yes
No
Transportation
Do you have a valid drivers license?
Yes
No
Are you willing to be of service and help other residents get to meetings?
Yes
No
Please describe
Do Not Possess Drivers License
Drivers License Currently Suspended
Do you need assistance obtaining your drivers license?
Yes
No
Do you need assistance reinstating your drivers license?
Yes
No
What is your primary mode of transportation?
Personal Vehicle
Family / Friend
Public Transit
Do you plan on having your personal vehicle at the property?
Yes
No
Vehicle Details
Make
Model
Color
License Plate Number
Do you have proof of registration?
Yes
No
Do you have proof of insurance?
Yes
No
Sensitive Information
Social Security Number
Additional Info
Please enter any other information about yourself or your situation that you feel we need to know
Submit Application