apply

How To Get Started

Sometimes not having a clean, safe place to sleep leads to decisions and/or actions that are later regretted. Or even worse, this leads to dangerous and life-threatening situations. Starting on a new path in life can begin is one step at a time. Apply to our program to start on your new path with us. We would love to support you as you begin your “success in life” journey!

Applying is easy. Simply fill out the application below. Once we receive the application, we will reach out to you for an interview. Then you pick a move-in date, finish remaining paperwork, and get ready to start the first steps to a new you. There is life after trauma!

Step 1

Step 2

Step 3

Step 4

Step 5

Step 6

Name:

Date:

E-mail:

Agency that works with you:

Birth Date:

Age

Vet:

Vet

E-mail:

Phone

ID Card:

D Card

SS card:

SS card

Income:

Healthcare:

Any Mental Health services or medication in the past or present? Please list:

Any Chemical dependency past or present and do you receive services? Where?:

What should we know about you to assist you? Please feel free to write in comments.

Emergency Contacts/Family or friends

1

Name:

Relation:

Address:

Phone number:

2

Name:

Relation:

Address:

Phone number:

Comments

Housing history

Times you lost housing and why:

Debt or LFOs:

Anything else:

Incarceration or Arrest histor

Any charges pending:

Charge:

County:

Status:

DOC Number_:

Are you working with any other organization or case managers are they helping with resources?

Work history

Are you working or looking for work? Type?

Do you plan on attending school or training and what type of education?

Counselor Signature

Resident Signature

CONSENT TO PROCEDURE AND ACCESS TO MEDICAL RECORDS

Post Trauma Initiative requires random urinalysis tests in the house and as a condition to entry to the house. We do not require access to medical records unless you are on medication(s) prescribed by a physician or on a medically assisted treatment for addiction.

1.1 Consent to Procedures: To arrange for and consent for urinalysis.

1.2 Access to Medical Records and Other Personal Information: The Principal hereby authorizes all physicians and psychiatrists who have treated the Principal, and all other providers of health care, including hospitals, to release to the Post Trauma initiative all information in the Principal’s medical records which the Post Trauma initiative may request. With respect to the Post Trauma initiative only, the Principal hereby waives all privileges attached to the physician patient relationship and to any communication, verbal or written, arising out of such a relationship. The Post Trauma initiative is authorized to request, receive and review any information, verbal or written, pertaining to the Principal’s physical or mental health, including medical and hospital records, and to execute any releases, waivers or other documents that may be required in order to obtain such information, and to disclose such information to such persons, organizations and health care providers as the Post Trauma initiative may designate.

Principal

Date

Post Trauma initiative

Date