Date Residency is Needed

Indicate soonest move-in date needed. If immediate, use today's date.

YYYY

Name

First Name

Last Name

Preferred Name

Street Address

City

State

Zip code

County

Describe Current Location

Addiction Treatment Facility

Incarcerated

Living with an abuser

Homeless Shelter

Homeless (on streets, living in car, short stay with friend/family)

Other

Phone number

Date of Birth

YYYY

Age

Relationship Status

Single

In a dating relationship

Married

Separated

Divorced

Widowed

Do you have children?

Yes

Please list ages of your children.

Do you have minor children not in your custody? If so, please explain.

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Relationship

Family Resource #1

Please give name, phone number and a relationship to family members that can be a resource to you.

Family Resource #2

Please give name, phone number and a relationship to family members that can be a resource to you.

Who referred you to this program?

Please include the name of the person and the name of the organization making the referral (if applicable).

What is the contact information for the person who referred you?

Include a phone number and email address.

DOCUMENTATION

Do you have your birth certificate in your possesion?

Yes

Do you have your social security card in your possesion?

Yes

TRANSPORTATION

Do you have a valid driver's license?

Yes

If you own a vehicle, is your insurance current?

Yes

EDUCATION

What is your education level?

No Degree

GED

High School Diploma

College Credits

College Degree

Describe any job training, certificates, or education you have completed.

CURRENT EMPLOYMENT

Are you currently employed?

Yes

Employer

Employment Location

How long have you worked there?

PREVIOUS EMPLOYEMENT

Business Name

Reason for Leaving

How long did you work there?

Business Name

Reason for Leaving

How long did you work there?

LEGAL INFORMATION

Have you ever been charged with a crime?

Select all that apply

Yes, convicted of a felony

Yes, convicted of a misdemeanor

Do you have any pending charges or warrants?

Yes

If yes, explain.

Are you a registered sex offender?

Yes

Are you on parole or probation?

Yes, parole.

Yes, probation.

Do you owe any legal fees?

Yes

HEALTH INFORMATION

What kind of health insurance do you have?

No medical insurance

Medicaid

Private medical insurance

Medical Conditions

Please describe any current or history of medical conditions

If so, when and where did you receive treatment?

Medications

Please list all prescribed and over the counter medications. Include: medication, dosage amount, and frequency. State NONE if not applicable.

Medication Allergies

Please list all medication allergies along with reaction. If no allergies please write NONE in the blank.

Food/ Environmental Allergies

Please list all food and environmental allergies along with reaction. If none please write NONE in the blank.

Trauma/Abuse History

Select all that apply

Physical abuse (history)

Physical abuse (current)

Sexual abuse (history)

Sexual abuse (current)

Emotional abuse (history)

Emotional abuse (current)

None

Substance Abuse History/Treatment

Current Addiction Treatment

Current Addiction (No Treatment)

History of Addiction Treatment

History of Addiction (No Treatment)

No History of Addiction

Psychiatric Disorders

Please describe any current or history of psychiatric disorders.

Did you receive treatment for any psychiatric disorders?

Yes

If yes, when and where?

Please include case manager and or contact person information.

List all addiction treatment stays with dates

If applicable

Did you complete the program?

Select one if applicable

If you did not complete the program, why not?

Do you smoke?

Please select one

Do you vape?

Please select one

Can you work a minimum of 32 hours per week to satisfy the program requirements?

Select one

If no, why not?

FINANCIAL INFORMATION

Do you own a car?

Yes

Do you receive SNAP benefits?

Select one

Do you receive SSI or SSDI?

Select one

If yes, do you have a payee or conservator?

Do you understand that Poiema charges a monthly program fee of $450?

Select one

Could you pay this within 30 days of admission?

Select one

TELL US ABOUT YOUR PLAN TO CHANGE

I need to make a change and the reasons are:

The following goals will help me make these changes:

Actions I can take to help me reach my goals are:

Describe a specific action and a time frame for reaching it

People interested in helping me achieve my goals are:

Possible ways that person can help me reach my goals:

Difficulties that may obstruct my goals and how I can manage them are:

List obstacles to change here

List possible ways to help manage those obstacles

Please write the story of your current situation and what lead you to this point in your life.

In telling your story please share: What is your current situation and what choices led you to this point? If you have a history of abuse, violence, or trauma, just mention it in a few words without going into detail.

PROGRAM BENEFITS AND GUIDELINES

Poiema Program Outlined

What WE Do Provide a safe place to live with a healthy community of support Assist you to set and work toward personal goals (Individual Service Plan) Guide you to integrate faith into daily living Connect you to healthy mentor (we train and support all of our volunteer mentors) Assist you in your quest to obtain and maintain employment Help you establish and maintain a budget Support you in developing a plan for transportation to meet program requirements Guide you to practice in healthy conflict resolution Provide case management (including access to resources for needs serviced by other providers) Provide education, classes, and groups to support your recovery Assist you to develop skills to successfully transition to independent sustainable living What YOU Do Adhere to program and house guidelines Obtain employment within 30 days (staff will assist you) Work 32+ hours per week (once employed) Attend program components weekly: recovery groups, program classes, church, and 1-hour individual meeting with Program Manager to work on personal goals Complete house chore assignments weekly Adhere to an 11pm curfew (exceptions made for work) Adhere to the no dating policy for 90 days (to give you time and space to recover and heal) Maintain sobriety (random drug tests performed; a positive test results in dismissal) THERE IS NO TOLERANCE FOR THE FOLLOWING: tampering with security cameras, physical or verbal abuse, intimidation, vulgar language, alcohol, drugs, gambling, pornography, sexual activity on the property, stealing, or weapons. Proof of these activities will result in immediate dismissal.

The information contained in this application is correct to the best of my knowledge.

I understand that making false statements at any time will result in termination of Poiema Movement services.

Person Completing Form

First Name

Last Name

Relationship to Applicant

Write self if the applicant is the one filling out the form.

Signature

Please fill in your first and last name to indicate agreement with the information you have included in this application.

Thank you!

We have received your application for residency at Poiema Restoration House. Once the Poiema team has had a chance to review your information we will reach out to you. If at any time you have questions or need an update on the status of your application you may reach out us via E-mail at Info@poiemamovement.com.

Best Regards,

Poiema Movement Staff

APPLICATION FOR RESIDENCY

Change HER Story