Real House Application (2023) CommentsThis field is for validation purposes and should be left unchanged.Personal detailsName* First Middle Last Age*Please enter a number from 1 to 118.Date of Birth* MM slash DD slash YYYY Gender*Contact infoAre you available to take calls during the day for an interview?* Yes No If yes, what phone number can we call you at during the day?Do you have a phone?* Yes No PhoneDo you have an email address?* Yes No Do you check your email regularly? Yes No Email Please provide the name and phone number of a person who will act as a contact for you.Contact NameContact PhoneAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you filling out this application on behalf of someone else?* Yes No If yes, what is your name?If yes, what is their relationship to you? (i.e. counselor, family member)?What is your phone number?What is your email address? Which is the best method to get in touch with you? Phone Email IncarcerationAre you currently incarcerated?* Yes No If you are currently incarcerated, what jail or prison are you currently in?*Date of incarceration* YYYY dash MM dash DD Do you have a release date?* Yes No Date of release* YYYY dash MM dash DD What is your current charge?*While incarcerated, have you spent any time in isolation?* Yes No How many days have you spent in isolation?*Please enter a number greater than or equal to 1.Why were you placed into isolation?*Personal recommendation*Please have your counselor or a staff member at the institution write a recommendation and sign it.Staff signature*Please note that typing your name into this box constitutes a written signature and endorsement of the recommendation content aboveStaff title*CourtAre you currently going through court?* Yes No Which jurisdiction(s) do you CURRENTLY have charges in?*Have you talked to your attorney about being court-ordered to the program?* Yes No Please provide details of this conversation*If you leave your attorney information blank, we will not follow up with your attorney and you will automatically be ineligible for the program.Attorney name*Attorney phone number*Attorney email* Probation/pre-trialAre you currently on probation/pre-trial?* Yes No Which are you on?*ProbationPre-trialWhere are you on probation/pre-trial?*Has your probation/pre-trial officer talked to you about REAL LIFE?* Yes No Please provide details of this conversation*Probation/pre-trial officer's name*Probation/pre-trial officer's phone number*Probation/pre-trial officer's email* Criminal historyDo you have a criminal history?* Yes No Please explain your criminal history*Are you a sex offender?* Yes No Please explain your sex offender history*Are you a violent offender?* Yes No Please explain your violent offender history*Have you been convicted of robbery or armed robbery?* Yes No Please explain your robbery history*Medical informationDo you take any medications?* Yes No List any medications you currently take and why you take them*Do you have any medical conditions that require medical attention within the next 6 months?* Yes No Please list any surgeries, existing medical conditions untreated, or any other medical condition*Are there any conditions that would limit your mobility or compromise your ability to negotiate stairs, a top bunk, or walking more than 2 blocks?* Yes No Please list any conditions that limit your mobilityHave you ever applied for disability?* Yes No Please explain your disability claim*Have you ever been awarded disability?* Yes No Please explain your disability award*Are you planning to file for disability?* Yes No Please explain why you are planning to file for disability*Have you ever been diagnosed with a mental health illness?* Yes No Please explain your condition*Have you ever been hospitalized for your mental health condition?* Yes No Please explain why you were hospitalized*Are you currently on medication for your mental health condition?* Yes No Please list and explain the medications you're taking for your mental health condition*List and explain any medications you've taken in the past for your mental health condition*When was the last time you saw a mental health doctor?*Other informationREAL LIFE is for people who are able to work after their first two weeks are over. Are you able to work?* Yes No Where have you worked in the past?*Have you been a part of any of REAL's Programs in the past?* Yes No Which programs were you a part of and when?*Why should we consider you for the REAL LIFE PROGRAM?*Are you currently in a recovery program?* Yes No If yes, what is the name of your program?What is the name of your counselor or case manager?What is their phone number?What is their email address? In the past 2 years, have you been in any recovery program?* Yes No List the programs, how long you were in each, and if you finished or were removed. If you were removed, explain why*REAL LIFE housing has 4 pages of rules which includes an 8 p.m. curfew, mandatory 2 weeks spent at the REAL LIFE Community Center before you are able to work, random drug tests, classes, work that is due weekly, and more. Please review the rules and sign them, and then scan and attach them to to submit with this application. Click here to view the rules document.Signed rules document*Accepted file types: pdf, doc, docx, jpg, jpeg, png, bmp, Max. file size: 2 GB. Are you willing to comply with the rules and obligations of the program?* Yes No Do you understand that if you are accepted into REAL LIFE, there is zero tolerance for using drugs and alcohol. You are also expected to follow all rules. If you do not, you will be removed from the program. You could be removed in the middle of the night if that is when the incident happens. Do you agree to this and understand?* Yes No Behavior and non-compliance gets people removed from the program. Even if you are passing drug tests, you can still be removed for bad behavior and not adjusting to the program. Do you understand?* Yes No Do you understand that if you are removed from REAL LIFE, it is NOT our responsibility to find you another housing plan or program?* Yes No Signature*Type out your name. This constitutes a written signature.Date signed* YYYY dash MM dash DD
