Apply for the program

This application helps us understand your needs and prepare a safe place for you. Every answer is private and handled with care.

It’s okay if you don’t have every answer right now. Fill in what you can — only name, phone, and email are required — and our team will walk through the rest with you personally.

Personal Information

Full Name *

Phone *

Email *

Current Residency

Address

City

State

Zip

Insurance Information

Insurance Type

ID Number

Group Number

Other Important Information

Date of Birth

Age

Gender at Birth

Marital Status

Children Names(separate with a comma)

Are you pregnant?

Any pending DHR cases?

If yes to DHR, explain

Are you a sex offender?

Any pending court cases?

Any pending warrants for your arrest?

Financial

Disability Payments

List Disability

Welfare

Social Security Payments

Unemployment

Safety & Medical

Emergency Contact

Emergency Phone

Do you have seizures?

If yes, last occurrence

Suboxone use

Substances you'll be detoxing from

Date of last substance use

Diagnosed Medical Conditions(separate with a comma)

Medications(separate with a comma)

Have you ever made a suicide attempt?

Have you ever purposely harmed yourself?

Do you have a valid driver's license?

Your information is private and handled with care by our team.

If you or someone you love is in immediate danger, call 988 (Suicide & Crisis Lifeline) or 911.