KAV/IZZY’s Resident Application Form For Housing

Today's Date

MM slash DD slash YYYY

Social Security Number:

xxx-xx-xxxx

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Birth Date

MM slash DD slash YYYY

Age

Veteran?

Yes

Highest Education Level:

Are you an out of state resident?

Yes

Where

What Pronouns do you currently use?

What gender do you identify with ( what were you assigned at birth)?

General Information

Do you have a valid photo id/drivers license?

Yes

Do you possess your birth certificate?

Yes

Do you currently receive any government subsidies or assistance/benefits?

Yes

If so, what? Insurance

Legal Information

Have you ever been incarcerated?

Yes

If “YES,” when?

How long did you serve?

For what crime(s) were you sentenced?

Do you have pending charges?

Yes

Are you currently on parole or probation?

Yes

Substance Abuse Information

List

Drug

First Use

Last Use

Method/Amount

If ‘over the counter’ or ‘other’ was selected, please list in detail:

Have you ever received treatment (inpatient or outpatient) for drug/alcohol?

Yes

Please give details: (dates, type, location, completion)

Have you lived in a sober living environment or halfway house?

Yes

Please give details: dates and reason for leaving:

Mental Health Information

Have you ever been formally diagnosed by a licensed psychiatrist, psychologist, or PCP, for any mental or emotional disorders?

Yes

If yes, please give details: (doctor, diagnosis and medication prescribed) Includin history of self harm or harm to others bi-polar depressiom

Do you take and prescription or over-the-counter drugs on a regular basis? Please list all medications and the purpose of taking them:

Any current Thoughts, idealations, plans to harm yourself, others, or others property

Yes

Explain:

Are you presently seeing a mental health professional:

Yes

If Yes, please list location, professional(s), frequency, and phone number:

Medical Information

Medication List:

Are you a diabetic?

Yes

If yes, type I or II:

Do you have any mobility issues (walking, stairs, bunk beds,) or do you have trouble sitting for long periods of time?

Yes

If yes, explain:

List all upcoming/past surgeries including dates:

Diagnosis :

If you are on disability, Why?

Why are you leaving where you are at and what steps have you taken to help resolve the reason you are leaving?

Have you ever worked and when was the last time? a month ago

Do you attend any recovery meetings?

Yes

Where:

What are your plans for paying rent ?

Tell me about a time you got into an argument with someone and how you solved it

Treatment choice, where do you plan on attending treatment at

About You

Explain why you want to live at Izzy’s and what you intend to get out of the experience: New begging somewhere positive that will allow him to work on himself

Additional Information

If you need more space to answer any previous questions or want to share additional information including what areas you need to work on to help with your recovery planning. Please use the lines below:

Affidavit

I have provided the above information and affirm that it is true and accurate to the best of my knowledge. I understand that Izzy’s is not responsible for any property damage or missing items or stolen items. I understand that I am moving into a Recovery housing and I have to attend outside treatment to stay here, and be compliant with all rules including but not limited to: paying rent, medication policy, remaining substance free, and not bringing substances into the home . I understand policies can be changed and updated as needed and shared in home meetings.

Name

First Last