Application for Residency Full Name *Phone *Email AddressDate of Birth *Are you affiliated with any of the following agencies? *Department of Children & Family ServicesVeterans AffairsDrug CourtDepartment of CorrectionsOtherNoneIf other agency please describe:Driver's License or State ID NumberSocial Security Number *Are you a veteran? *YesNoWhat is your income source (select all that apply)? *WorkingDOC Housing VoucherHARP FundingSSISSDIOtherIf other income please describe:Do you have healthcare? *Yes, MedicaidYes, state healthYes, private insuranceYes, insurance through employerNoDo you now, or have you in the past, recieved mental health services? Please list dates and any medications received. *Do you now, or have you in the past, suffered from substance use disorder, including alcoholism? Please list dates and any services recieved. *Do you now, or have you in the past, experienced housing insecurity? Please list dates and circumstances. *Please list any charges, historical or pending, including charge, county, and status as well as DOC number. *Are you working with any other organization or case managers and are they helping with resources? *Are you working or looking for work? What type? Do you plan on school or training and what type?Emergency Contact(s)Name *Relation to you *Street Address *Phone *Is there anything else we should know about you in order to assist you? Please feel free to write about it here.Submit Application
