Application for Services Name * First Name Last Name Date of Birth * DOB MM DD YYYY Were you referred by a criminal justice organization? * (probation, parole, jail, community corrections etc.) Yes No Referral Source * (Name of probation officer, community corrections officer name and phone number) Address * Current Location Address Address 1 Address 2 City State/Province Zip/Postal Code Country Contact phone number * (###) ### #### What services are you interested in? Recovery Residence (women only) Faith-Based Services (emergency housing, case management etc) Sober Living Date available Dates are target dates. Once approved you will receive your official move-in date. MM DD YYYY Substance and Mental Health History * Opioids Methamphetamines Alcohol Domestic Violence Mental Health Other substance use Provide a brief description of your substance use and mental health history * Currently Employed Yes No Employer Name and Address (Current employer only) Income per month $ Recovery Housing History * (Please list all Recovery Residences you've previously lived) Why is it important this time for you to seek Recovery? * (What makes this time different?) Current Medical & Mental Health History (Ex. Diabetes, Depression, Bipolar etc.) Current Medications and Physician * (Add physician name and medications prescribed) What is an area you would like to improve in your life? * (Please provide details) What do you want to gain from your stay at Victory House? * Thank you for your application. A member of our team will be in touch with you soon. If you are a service provider or criminal justice partner, please contact us at the office 260-5576183.