Applicant Full Name?
Applicant Phone Number?
Applicant Email?
Application Date?
What location are you applying for?
Please Select An Option
Charlotte, NC
Who referred you? How did you hear about us? Kindly put name of person/agency and phone number. Give Credit!
Who Is The Application for?
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Myself
Family Member
A Client
Gender?
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Male
Female
Other
Date Of Birth
Age?
Height?
Weight?
Are you pregnant?
Please Select An Option
Yes
No
Are you aware that this is a shared living home?
Please Select An Option
Yes
No
Have you lived in shared housing before?
Please Select An Option
Yes
No
Current Living Situation?
Please Select The Option
Group Home shared living
Living with family
Living by myself
Living with roommates
Living in a motel
Homeless with no permanent place to live
Current Address?
How long would you like to be a guest at our home? *
Please Select The Option
1 - 3 months
4 - 6 months
7 - 12 months
1 - 2 years
Funding Source
Please Select The Option
Self Pay
Social Security Insurance
Social Security Disability Insurance
Government or State Organization
Non Profit Organization - Rent Assistance
Are you Employed?
Please Select The Option
Yes
No
If you are employed, what are your hours/shift and what city do you work in?
If you are not, do you intend to apply for a job within 1 month of your arrival in Daphne’s Haven?
Please Select The Option
Yes
No
If you don’t intend on working or going to school, etc. explain why not and what you plan on doing with your daytime hours?
Would you consider appointing a Representative Payee to ensure timely rent payments aiding the success of your housing? If not, your rent will be due in advance to assure good faith.
Please Select The Option
Yes
No
Criminal History
Please Select The Option
I Have A Felony
I Have A Misdemeanor
I Have No Criminal History
If yes, please provide details of any criminal charges or convictions you have, including the nature of the charges and any associated legal outcomes.
Do you have a probation officer, etc? If so, what is their name and phone number and extention?
Funding Source Details : 1. What is the monthly income that you receive?
Funding Source Details : 2. What is the specific date that your payment is disbursed? 2a. Do you have a guarantor assisting you with the bed-rate fee?
Funding Source Details : 3. Any additional Income Information ie. Part-time job?
Please disclose any existing medical/mental conditions or health concerns that we should be aware of. What have you been diagnosed with, if any?
Do you have any food or drug allergies? If yes, please elaborate.
Are you currently attending Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings? If yes, please specify which one(s). If no, do you need to find a meeting to attend? If this doesn’t apply, write N/A
Are you currently taking any medications?
Please Select The Option
Yes - Prescription medication
Yes - Over the counter medication
No
If yes, please provide a list of the medications you are taking, including their names and dosages.
Are you currently taking any medications as part of your recovery treatment? If yes, please specify which one/s.
Do you have a sponsor or are you/will you be actively seeking one? (Please specify) If this doesn’t apply, write N/A
How long have you been in recovery? Please provide details about your recovery journey.
Are you involved in any other support groups or programs related to recovery? If this doesn’t apply, write N/A
Have you completed any rehabilitation or treatment programs? If yes, please provide details. If this doesn’t apply, write N/A
Are you coming from another group home? If yes, please specify which one and for how long you've been living there and the reason for leaving.
Do you have a history of relapse? If yes, please provide details and specify if you have a relapse prevention plan in place.
Do you have any specific needs or requirements related to your recovery journey that you would like us to be aware of?
Primary Mode of Transportation?
Please Select The Option1
Public Transportation
Personal Vehicle
Do you smoke?
Please Select The Option
Yes
No
If yes, what do you smoke?
Do you agree to a drug test prior to your move-in date?
Please Select The Option
Yes
No
Do you agree to random drug tests?
Please Select The Option
Yes
No
Preferred Move In Date?
Any important details we should be aware of, not yet addressed?
Documents? Below you can upload documents that we will require such as ID/ Bank Statement/ SS Award Letter
Attachments
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