Resident Application Form For Housing

KAV/IZZY’s Resident Application Form For Housing

Applying for housing in:(Required)

Social Security Number:(Required)

Last Name:(Required)

First Name:(Required)

Street Address:(Required)

City:(Required)

ZIP / Postal Code:(Required)

County:(Required)

Home Phone:(Required)

Cell:

Email Address:(Required)

Highest Education Level(Required)

Are you an out of state resident?(Required)

What Pronouns do you currently use?(Required)

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

General Information

Do you have a valid photo id/drivers license?(Required)

Do you possess your birth certificate?(Required)

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

If so, what?

Legal Information

Have you ever been incarcerated?(Required)

For what crime(s) were you sentenced?(Required)

Do you have pending charges?(Required)

Are you currently on parole or probation?(Required)

Upcoming hearings?(Required)

If yes, give dates.

Substance Abuse Information

Drug

First Use

Last Use

Method/Amount

Over the Counter Drugs or Other Subs

Please indicate the name of the drug, first use, last use and the method/amount.

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

Please give details: dates and reason for leaving:(Required)

Mental Health Information

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

If yes, please give details: (doctor, diagnosis and medication prescribed) Including history of self harm or self harm.

Do you take prescription or over-the-counter drugs on a regular basis? Please list all medications and the purpose of taking them: Hypertension. Enlarged prostate, type 2 diabetic. All treated by PCP since 2011. Any current Thoughts, ideations, plans to harm yourself, others, or others property.(Required)

Are you presently seeing a mental health professional:(Required)

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

Medical Information - we do not accept cannabis, any stimulants, benzos, suboxone over 16 mg daily, methadone and Gabapentin are based on review. We also do not take clozaril, or subuclade, or subutex.

Medication List: See above

Are you a diabetic?(Required)

Do you have any mobility issues (walking, stairs, bunk beds,) or do you have trouble sitting for long periods of time? Residents must be able to walk, go up and stairs , and complete all ADLS independently.(Required)

List all upcoming/past surgeries including dates:(Required)

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? Insurance issues. He is reaching out to other facilities. He is starting with us(Required)

Have you ever worked and when was the last time?(Required)

Do you attend any recovery meetings Where:(Required)

What are your plans for paying rent ?(Required)

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

Treatment choice, where do you plan on attending treatment at(Required)

About You

Explain why you want to live at Izzy’s and what you intend to get out of the experience:

\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:

If you are dishonest on the application it is an automatic discharge due to not being honest.

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.

Signature:(Required)

Print Name: Sign Name: Patient is offsite via phone with Logan/ Sidney izzys house manager

Approved by: _________________________

Denied by: __________________________ Why?_________________________

KAV/IZZY’s Resident Application Form For Housing

General Information

Legal Information

Mental Health Information

About You

Affidavit

CONTACT

ABOUT US

NEWS