Hope Town Website Application

Complete this application and submit it for review. Many of us will be automatically notified and someone will reach out to review it together with you. We are excited to potentially partner with you on your recovery path! This housing application form is completely secure (HIPAA Compliant).

Date*

First Name*

Middle Initial

Last Name*

DOB*

Gender

Select or enter value

Phone #*

Please give us a good number to reach you and be sure to answer or respond quickly, if you want to be considered.

Email Address*

If you don't have a good email address for the next month then just enter N/A

Address*

If you don't have an address to give right now....just enter N/A. Be sure to let us know if you have ever been a Portage County resident.

City*

Even if you have no home right now - put the last city you lived in

Have you lived in Recovery Housing before?*

yes

If yes, describe here where, when, how long, etc..

How did you hear of Hope Town?*

ID Cards*

Do you have Driver's license or state ID, SS Card and or Birth Certificate? This helps us to know if you'll need help obtaining the ID's needed for insurance and employment

Yes

Not sure

Date of Last Use*

This is really important. Recovery housing is not a detox or residential treatment facility. We do not have medical or counseling staff on site, ever. We can help determine with you based on many factors if you have been abstinent long enough to do well here or we can help you find a better match until then.

Recent using history*

This helps us know more about your recent patterns.

Prior Treatments*

It helps us to know what treatments you have tried in the past year. Organizations, length of stay, if it helped, etc...

Who is your current treatment provider

What type of treatment and where?

Are you on or planning on being on MAT?*

(MAT) Medication Assisted Treatment (i.e. vivitrol, suboxone, etc..)

Name of current MAT provider (If applicable)*

Case Manager / Discharge Facilitator

This applies usually when someone is coming out of residential treatment, jail or prison

Do you have a P.O.? If yes, list name and county*

Legal Issues*

We mostly want to know any court dates or community corrections (probation) so that we can support those needs.

Insurance*

While insurance does not pay for the housing, it is important to know this up front. We can help you get signed up so you have it for medical and treatment coverage!

Is insurance Active?

Select or enter value

Describe any medical or special needs*

Current RX Medications

Sexual Offense*

Our housing is located close to a school so if you have a sexual offense that prohibits you from living here...we want you to know up front (and we do screen every resident).

Yes

Do you know anyone that stays at Hope Town?*

Employment*

If you have a job to go to, great! Know that the start date, shift and number of hours worked per week will need to be agreed to by Hope Town (based on our policies). If you don't, we can help with employment.

Rent*

Our Level Two Men's housing is $450/month due before you move in. No background checks (other than sexual offenses). No credit checks, security deposits or utility costs!

Our Level One Men's housing is new and is usually when a person is 10 months or more in recovery before one can apply. It also requires rent, deposit and some utilities as it is a more responsible, less restrictive level.

Need help talking to you family about this?

Date you want to move in?*

Additional Comments

Please use this section to add in any additional questions, thoughts or information that you'd like us to know

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