Supervised Housing Application

Thank you for your interest in Herron Homes Supervised Housing.

Please take your time as you answer all questions completely.

When finished make sure to click on the submit button.

THIS FORM MUST BE COMPLETED BY PROSPECTIVE PARTICIPANT

PLEASE DO NOT PRINT

First name

Last name

Phone Number

Birthday

Month

Day

Year

Which facility are you currently located at?

Discharge Date

What is your drug(s) of choice?

How long have you used substances? What was your last date of use (list separately if needed)?

Have you ever been to rehab/detox?

Have you attended any programs that have helped in the past?

What do you think a sober living/supportive housing is for?

Describe your past and current living situation? Where will you go after programming is complete?

Why do you want to participate in supportive housing?

What plans do you have for your recovery?

What support do you plan to receive from our program?

Are you currently on probation or parole?

Have you ever been charged or convicted with a sex crime? If so, please elaborate.

Do you have any children? Are you actively participating in their care (If yes, describe)? Are you providing financial support?

What is your current relationship status? Are you single, married, separated, divorced, other (explain)?

What supports do you have in place right now?

Please list all medical diagnosis (Dates of diagnosis if available)

Do you currently use any type of medical devices (wheelchair, cane, walker, shower chair. If yes ,include which device and for how long the intended use is for)?

Do you have any upcoming medical, behavioral, court, probation, CYFD, etc. appointments? (Include place, address, phone number, date and time)

Please list all mental health diagnosis (Dates of diagnosis if available)

Please list all medications with dosage and frequency (fax list if necessary to 505-514-0732)

Our current policy doesn’t allow out-of-county visits. Will that pose any difficulties for you? If so, describe)

Is there anything else you would like us to know about you?

Please check all that apply:

I acknowledge that I have read the HH Supervised Housing Living Policy & Procedures.

I understand and agree to all HH Supervised Housing Policy & Procedures

I have questions about HH Supervised Housing Policy & Procedures

By signing below you agree that all information is true and correct to the best of your knowledge.

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