Rental Application
As of 4-23-2022, We are ONLY accepting new applicants who’ve achieved the below listed criteria to ensure the utmost success for our residents. A combination of six months clean and a successful graduation from Halfway Housing. Six months clean and completion of a State Drug Treatment Program with certification. Six months clean with current involvement in the Treatment Court Program.
Today's Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Date of Birth
*
Clean Date
*
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Month
-
Day
Year
Date
Inpatient Treatment Facility
*
Discharge Date
*
Counselor's contact
*
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Area Code
Phone Number
Counselor's Email
*
example@example.com
Phone number I can contact you
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Area Code
Phone Number
Do you have a medical/psychiatric diagnosis?
*
Yes
No
If yes, what is your diagnosis?
*
List medications (At this time we can not accept, Neurontin, gabapentin or M.A.T.)
*
Are you currently medication compliant?
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Yes
No
Do you have past criminal charges?
*
Yes
No
If yes, explain
*
Are you currently on probation/parole?
*
Yes
No
If yes, list county, name and number of your current probation/parole officer.
*
Do you have children?
Yes
No
If yes, where will they be residing while you live in a recovery home?
Names and ages of children, if applicable.
Who are your "Clean" supports including sponsor and family members, if applicable?
Do you receive TANF?
Yes
No
If yes, how much do you receive monthly?
Do you receive SSI?
Yes
No
What is your monthly income?
How are you going to afford rent and food?
*
Do you have any health precautions that would prevent from you being unable to abide by H.E.R. Home policies?
*
Yes
No
If yes, please explain
Do you have allergies?
What steps have you taken to prepare yourself to live in a Recovery program?
*
List some of the barriers that have prevented you from staying clean.
*
If accepted, how could you contribute to H.E.R. Home and what would you take?
*
How did you hear about H.E.R. Home?
*
Do you understand that recovery is your number one priority and that you will need to continue to work towards a healthy lifestyle in order to gain independence in your life?
*
Yes
No
Do you certify that all of your answers are true and complete to the best of your knowledge?
*
Yes
No
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