Assessment

What date are you hoping to enter our program? *

First Name*

Middle Initial*

Last Name*

Phone Number*

Email

Contact Person*

Birthdate*

County of residence (must provide proof)*

Henry

Fayette

Rush

How long have you been homeless*

Reason for homelessness*

Program T.R.A.C. Choice*

Emergency - Short-term stay 30 Days

Reentry - 14 Months

Rise & Rebuild- 14 Months

Genesis- 12 Months

Vocational 14 Months

Income*

No Income

Part-Time

Full-Time

SSI

Disability

Employer

Are you currently incarcerated*

Yes

No

Do you have any criminal charges sexual In nature*

Yes

No

Are you currently on or will you be on*

On Probation

On Parole

On House Arrest

On Drug Court

Does Not Apply

Do you have any serious health conditions*

Yes

No

Have you been prescribed medication for mental illness (Residents prescribed medication for mental health conditions must be current with and compliant on all prescribed medications.)*

Yes

No

Are you currently taking Suboxone?*

Yes

No

Can you provide proof of a valid prescription along with a taper plan from your prescribing provider for your Suboxone.?*

Yes

No

Does Not Apply

Can you climb steps & practice personal hygiene independently*

Yes

No

Do you have a state ID or jail ID*

Yes

No

What specifically about our Faith-based facility made you choose us over other sober living options?*

How do you think a Faith-based sober living environment can help you achieve your goals?*

If accepted into our facility, what is your plan for recovery and renewal during your time with us?*

What does "being responsible for your actions" mean to you?*

How do you feel about living in a highly structured, faith-based sober living environment, and what role do you see faith and structure playing in your recovery and renewal.*

Can you pass a drug screen?*

Yes

No

I understand that I cannot vape while living at our facility.*

Yes

Eligibility Requirements

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