Application for SHIP HousingTo be accepted into SHIP Housing an applicant must complete all questions in this application and be interviewed by the SHIP staff. Phone interviews can be arranged if needed. Carefully read the application and honestly answer the questions. SHIP provides separate facilities for Men and Women. Safe and Sober Housing is a step down program that does not have a predetermined length of stay - how long you stay depends on you, your needs, and your source of funding.Type of Housing *Men's HousingWomen's HousingWhen do you need housing? *ImmediatelyLaterSpecial ProgramsHomelessVeteransDate Housing NeededDo you have a Professional Assessment for a Dual-Diagnosis i.e. Mental illness combined with a substance use disorder. This diagnosis is generally provided by a psychologist, psychiatrist, counselors, medication managers, psych hospitals, etc. *YesNoFirst Name *Last Name *Email Address *Phone *Date of Birth *MonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212421232122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeAre you employed? *YesNoWhat's your expected income next month? *USDWho is your employer? *How many hours do you work per week? *Each member of the house is required to pay their share of the housing expenses. What is your source of income? (please list) *If you're not working, you will be expected to actively seek employment a minimum of 10 hours of works skills per week and 10 job searches per week. Do you agree to this? *I agree to particiapteI don't agree to participateSHIP houses are recovery homes and require that residents be in recovery from alcohol or substance abuse, please indicate the type of program you are participating in to work on your recovery. *Detox/Allumbaugh HouseResidential TreatmentOutpatient Treatment12-Step ProgramOtherAre you an alcoholic? *YesNoDate of your last drink? *Are you a drug addict? *YesNoDate of last drug use? *What are your drug(s) of choice? Name 2. *Currently, what are you doing to address your drug/alcohol problem? *Are you currently drinking alcohol and/or using addictive drugs? *YesNoWhat is your criminal history? Length/location of incarceration? Release Date? Start with most recent. *Have you ever been supervised on felony probation/parole? *YesNoHas your probation/parole ever been revoked? *YesNoAre you currently on court supervision? *YesNoAre you currently under the supervision of the Idaho Department of Corrections? *YesNoWhat is your IDOC number?IDOC Facility?Case Manager's Name?Case Manager's Phone NumberWill you be topping your time? *YesNoTentative Parole Date?Please indicate which, if any, of the following you're involved with:ProbationParoleDrug CourtMental Health CourtCourt Ordered to TxIf you're involved in any of the above, who do you report to?Do you have any felony convictions? *YesNoPlease list all felony convictionsHave you been convicted of drug manufacturing or distribution? *YesNoHave you been convicted of any violent crimes? *YesNoPlease explain:Are you a sex offender? *YesNoAre you required to register? *YesNoPlease explain:Have you ever been convicted of Arson? *YesNoDo you have any history of violent behaviors? *YesNoHave you ever attended or are you currently attending anger management classes? *YesNoAre you currently taking any prescribed medications? *YesNoWhat are 2 goals that you want to complete in the next 90 days while residing in SHIP's Safe & Sober Housing? *How will you pay to live in SHIP's Safe & Sober Housing? Ask your PO if you qualify for transitional funding or call BPA at 800-922-3406. Your funding must be in order before SHIP will allow you into a house. Have a check sent to our office within the week of you release. *Complete ApplicationPlease do not fill in this field.