Apply Now - CSTL Services

Personal Information

Today's Date(Required)

Date Graduating from TX program

Name(Required)

First Last

Date of Birth(Required)

Phone(Required)

Are you homeless?(Required)

What is your current or most recent residential address?(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is your last known address a friend or family member's?(Required)

Are you leaving another program/prison?(Required)

Where?(Required)

Do you have a case worker?(Required)

If yes, please give their name and contact info:(Required)

If yes, please list your medications:(Required)

When was the last time you used drugs or alcohol?(Required)

List any Physical issues you have:

Do you have any income?(Required)

If yes, explain:(Required)

Do you currently have G.A. or any state assistance programs?(Required)

GRH funding?(Required)

If yes, from which county?(Required)

Are you clean and sober now?(Required)

How long have you been clean and sober?(Required)

Drug(s) of choice:(Required)

How many treatment programs have you attended?(Required)

How many months total have you spent in treatment?(Required)

What is the most recent treatment facility that you have visited?(Required)

Marital Status(Required)

Children?(Required)

If so, how many?(Required)

Please list an emergency contact person:

Name(Required)

First Middle Last

Home or Cell Phone(Required)

Work

Current Employment

Are you currently employed?(Required)

Name(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Position(Required)

Supervisor Name(Required)

First Last

From:(Required)

To:(Required)

Please answer the following questions:

Do you have a driver's license?(Required)

State?(Required)

Date of Birth(Required)

County Case #(Required)

In what county do you have residency? (If homeless, please write "N/A")(Required)

Why do you want to move to Anoka/Columbia Heights?(Required)

Have you been convicted of a violent crime, theft, sexual crime or arson within the past ten years(Required)

If yes, please explain:(Required)

Probation or Parole

Are you in drug court, on probation, parole or obligated to restitution of any kind?(Required)

If yes, provide name and phone number of supervising officer and/or court (this does not mean we will be calling your agent for any additional information):

Name(Required)

First Last

Department(Required)

Phone(Required)

References / Family and Friends

Family Member - Name

First Last

Family Member - Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Family Member - Phone

Family Member - Email

Friend - Name

First Last

Friend - Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Friend - Phone

Friend - Email

Medication

Please use this space to list all medications you are taking, the prescribing doctor and their phone number. Use additional paper if more space is needed.

Medication

Doctor

Phone

Medication

Doctor

Phone

Medication

Doctor

Phone

Medication

Doctor

Phone

Medication

Doctor

Phone

Special Information

Please list any special information (example: 3rd shift worker, pet allergies or any other relevant information). Use additional paper if more space is needed

Special Information #1:

Special Information #2:

Certification Agreement

I agree my stay is conditional upon rules. If asked to leave for violating these rules, I will immediately.(Required)

Initial

I agree I am a guest in the board and lodging sober facility. I agree I do not have tenant rights.(Required)

Initial

I agree to pay my monthly guest fee in advance if the guest has monthly income for self-pay.(Required)

Initial

I agree house managers/owners/operators/directors have the right to change rules as necessary.(Required)

Initial

I agree this application is true and complete to the best of my knowledge.(Required)

Initial

I agree falsification or misrepresentation will be cause to suspend my guest status.(Required)

Initial

I agree if I perpetrate any of the following acts I will be asked to leave within a period of 24 hours or less.(Required)

Initial

I agree not to carry or possess a gun or other weapons on the property.(Required)

Initial

I agree not to carry or possess any illicit drugs or alcohol on the property.(Required)

Initial

I agree not to threaten to harm any person, blackmail or extort guests or staff.(Required)

Initial

I agree not to steal property from other CSH guests, staff or facilities.(Required)

Initial

I agree not to refuse to take a drug test, a refusal of a drug test is a positive result.(Required)

Initial

I agree if I am accepted into supportive housing, I will follow program requirements signed upon admission, I agree I will follow program rules, I agree I will follow program curfews.(Required)

Initial

I have read and reviewed the information provided in this application and the above statements.

The above information that has been provided is true to the best of my knowledge.(Required)

Initial

I authorize CSTL to use the above information to help determine my eligibility for housing.(Required)

Initial

I understand that by signing my name on the signature line below and submitting this application via fax, email, mail or hand delivery, I certify that I understand all parts of it and have answered all questions completely and truthfully.

Signature(Required)

First Last

Date(Required)

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.

Christ Satisfies Transitional Living

Residential Licensed Facility & Services

SOBER HOUSING BOARD AND LODGING APPLICATION

SOBER HOUSING BOARD AND LODGING APPLICATION

Personal Information

Please list an emergency contact person:

Current Employment

Please answer the following questions:

Probation or Parole

If yes, provide name and phone number of supervising officer and/or court (this does not mean we will be calling your agent for any additional information):

References / Family and Friends

Medication

Special Information

Certification Agreement

I have read and reviewed the information provided in this application and the above statements.

I understand that by signing my name on the signature line below and submitting this application via fax, email, mail or hand delivery, I certify that I understand all parts of it and have answered all questions completely and truthfully.

Disclaimer:

CSTL Services does not discriminate on the basis of race, color, religion, gender, gender expression, age, sexual orientation, disability or national origin.

Contact

Phone

Email

Address