Kleen Street Recovery Housing Program

1

Applicant Information

Date

Applicant Name

Date of Birth

Social Security Number

Ethnicity

Gender

Male Female Other

Phone

Cell Phone?

Yes No

Email

Treatment / Correctional Facility

Anticipated Release Date

Counselor / Probation Officer Name

Counselor / P.O. Contact Info

Last Permanent Address

Dates Lived at That Address

Have you stayed in a shelter in the past 2 years?

Yes No

Name of Shelter

Shelter City

Shelter State

Dates at Shelter

Reason(s) You Need Housing — Check all that apply. Mark your primary reason with the ★ button.

Primary Reason (type the reason marked above)

Explanation (provide detail when necessary)

Place of Birth

How Long Have You Lived in Vancouver?

Are You a U.S. Citizen?

Yes No

If Not a U.S. Citizen, Specify Immigration Status

2

Military Service

Military Branch?

Type of Discharge?

Do You Have Your DD-214?

Yes No

3

Emergency Contact Information

Who should we contact in case of emergency? (Please list 2.)

Emergency Contact #1

Name

Relationship to You

Address

City

State

ZIP Code

Phone Number

Emergency Contact #2

Name

Relationship to You

Address

City

State

ZIP Code

Phone Number

4

Family History

Did any of the following occur in your household while you were growing up? Check all that apply.

Who did you live with most often while growing up?

Do You Have Siblings?

Yes No

# of Sisters

# of Brothers

Relative who lives close to you

Name

Relationship

Phone Number

Email

City

State

Briefly describe your family history (e.g., parents' occupations, divorces, supportive or abusive environment, physical/emotional)

Most positive things about your family

Most difficult things about your family

Was there any drinking, alcoholism, drug abuse, mental health issues, or physical abuse?

5

Household Information

Are You Pregnant?

Yes No

Due Date (if applicable)

Are You the Legal Guardian of Your Children?

Yes No

Do You Have Children Who Do Not Live With You?

Yes No

If you have children who do not live with you, please provide their names, ages, living arrangements, and reason for separation

Have you ever been married or divorced? Specify spouse's names and marriage/divorce dates

Briefly describe reasons for separation or divorce

Are You Anticipating Reconciliation?

Yes No

Do You Have a Significant Other?

Yes No

If yes, provide significant other's name and location

6

Child Protective Services

Has CPS Been Involved With Your Family?

Yes No

Do You Currently Have an Ongoing CPS Case?

Yes No

Date of CPS Involvement

Caseworker Name

Caseworker Phone Number

State and County

Reason for CPS Involvement

Children Involved (names and ages)

Court-Ordered Services

Mandatory Parenting Classes Required?

Yes No

Date Completed (if applicable)

7

Domestic Violence

Have You Ever Experienced Domestic Violence?

Yes No

Name of Perpetrator

Is a Restraining Order Currently in Effect?

Yes No

State and County (of Restraining Order)

Names of Persons Involved in Restraining Order

Who do you use for emotional / social support? — Check all that apply.

8

Income Information

What Are Your Sources of Financial Support?

Amount Per Month ($)

Financial Caseworker Name

Caseworker Phone Number

Client ID Number

State

Did you receive any of the following? (Yes / No and Amount)

Benefit	Yes / No	Amount / Month

Other Cash Assistance — Specify

9

Employment History

Are You Currently Employed?

Yes No

Are You Looking for Work?

Yes No

Current Employment

Employer Name

Employer Address

Hours Per Week

Wages ($)

Pay Frequency

Weekly Monthly Bi-Monthly

How Long at Current Job?

If Not Looking for Work, Specify Reason

How Long Have You Been Unemployed?

What Type of Work Are You Looking For?

Please List Up to 4 Previous Employers

#	Name of Employer	Dates of Employment	Reason for Leaving
1
2
3
4

Which Was Your Most Enjoyable Job?

Why Did You Like It?

What Is Your Best Job Skill?

What Are Your Employment Skills?

10

Education

Do You Have a High School Diploma?

Yes No

Year of Graduation

Do You Have a GED?

Yes No

Year of GED Completion

Would You Like to Obtain a GED?

Yes No

Do You Have a Learning Disability?

Yes No Not Sure

Do You Have Any College Education?

Yes No

Degree(s) Earned

Name and Location of College

Other Education, Degrees, and Dates Received

Do You Plan to Go Back to School or Any Educational Institution?

Yes No

If Yes, Please Tell Us Your Plans

11

Substance Abuse

Describe Your Substance Abuse History and How You Plan to Stay Clean and Sober

Do You Currently Drink Alcohol or Use Drugs?

Yes No

If Yes, Specify Substance(s)

Date of Last Use / Drink

Substance Used at Last Use

Do You Attend 12-Step Meetings?

Yes No

How Often?

List All Inpatient and Outpatient Treatment — Dates and Locations

Type (Inpatient / Outpatient)	Facility / Location	Dates

12

Criminal & Legal History

Please List Your Criminal History

Do You Have Any Current Pending Legal Issues or Lawsuits? List Each and Current Status.

Do You Have Court / Probation / Parole Requirements? Please List and Specify County Involved.

Do You Have Legal Financial Obligations?

Yes No

Amount Owed ($)

Name of Probation / Parole Officer

Probation / Parole Officer Phone

Are You Currently Incarcerated?

Yes No

Expected Release Date

List of Incarcerations

Facility / Location	Dates	Charge / Reason

13

Medical & Mental Health History

List Any Mental or Physical Problems That Prevent You From Working

Have You Ever Thought of or Attempted Suicide?

Yes No

Date of Last Time You Thought About Suicide

Suicide-Related Treatments or Hospitalizations — Please Give Dates and Briefly Describe

Have You Ever Seen a Counselor for Anything?

Yes No

If Yes, What Were You Seeing Them For?

Have You Ever Been Diagnosed With Any Mental Health Issues? (e.g., Depression, Anxiety, ADHD, Bipolar, Schizophrenia, etc.)

Are You Currently Participating in Mental Health Treatment?

Yes No

Name and Location of Treatment Provider

Have You Ever Taken Mental Health Medications?

Yes No

Are You Currently Taking Any Medications?

Yes No

Please List All Medications You Are Taking (Prescribed and Non-Prescription)

14

Transportation

Do You Have a Valid Driver's License?

Yes No

Do You Own a Vehicle?

Yes No

Do You Have Vehicle Insurance?

Yes No

Driver's License Number

License State

License Expiration Date

Vehicle License Plate Number

Plate State

Vehicle Year

Vehicle Make

Vehicle Model

If You Do Not Have a Valid Driver's License, What Do You Need to Do to Obtain One?

15

Residence History — Last 3 Years

Begin with your most recent residence. Include address, city, state, and length of stay.

#	Address	City	State	Length of Stay
1
2
3

16

Housing

Do You Plan to Stay in Clark County?

Yes No

If No, Why Not?

How Did You Hear About Kleen Street?

17

Goals & Objectives

Briefly Describe Your Goals for Yourself and Your Family

How Do You Think Kleen Street, a Recovery-Based / Home-Based Navigator, and Your Case Manager Can Help You Achieve These Goals?

18

Applicant Certification

I certify that the information given to Kleen Street on household composition, income, net family assets, allowances, and deductions is accurate and complete to the best of my knowledge and belief. It is further understood that I must immediately report any changes in my household composition or my income to Kleen Street. It is understood and agreed that the failure to report changes and/or submitting false statements or information is grounds for termination from the Kleen Street program.

I have read — or have had read aloud to me by Kleen Street staff — this application. I understand and agree to the Applicant Certification statement above.

✍

Electronic Signature — Legal Notice: By drawing your signature below, you are providing a legally binding electronic signature pursuant to the Electronic Signatures in Global and National Commerce Act (E-SIGN Act), 15 U.S.C. § 7001, and the Washington Electronic Authentication Act (RCW 19.34). Your electronic signature carries the same legal weight and effect as a handwritten ink signature and constitutes your full agreement to all terms and statements contained in this application.

Applicant Signature

☞ Sign here with your finger or stylus

Not yet signed

Date Signed

19

Kleen Street Recovery — Authorization for Release of Information / Waiver of Liability

I authorize the release and receipt of information about me, including documentation and other materials pertinent to my participation in Kleen Street Recovery Programs, from the following agencies:

Department of Corrections
Community Services Northwest
Columbia River Mental Health
Clark County Sheriff
Lifeline Connections
Seymour Community Health Center
Share House
City of Vancouver
Department of Social and Health Services (DSHS)
Washington Child Protective Services
Safe Choice
Clark County Therapeutic Drug Court
Department of Children and Family Services
Lifeline Detox
Reindeer Detox

The Following Is a List of Other Agencies / Individuals From Whom Information May Be Requested

I understand that my information is being secured in a database.

I agree that photocopies of this authorization may be used for the purpose stated above. This Release of Information shall be valid for one (1) year.

I hereby release Kleen Street and all individuals connected with this organization from any liability for acts performed in assisting me in good faith. Kleen Street will not be liable for any personal injury or loss of property during my program participation.

In signing this release, I recognize that Kleen Street is a nonprofit entity which is providing a service and assistance to me at my request.

Client Initials — I agree that photocopies of this authorization may be used for the purpose stated above

Client Signature

☞ Sign here with your finger or stylus

Not yet signed

Date Signed

Kleen Street Staff Signature

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Staff Date