Housing Application

Application for SHIP Housing

To 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.

Date Housing Needed

Do 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. *YesNo

First Name *

Last Name *

Email Address *

Phone *

Date of Birth *

Month

Day

Year

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Are you employed? *YesNo

What's your expected income next month? *

USD

Who 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 participate

SHIP 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 ProgramOther

Are you an alcoholic? *YesNo

Date of your last drink? *

Are you a drug addict? *YesNo

Date 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? *YesNo

What is your criminal history? Length/location of incarceration? Release Date? Start with most recent. *

Have you ever been supervised on felony probation/parole? *YesNo

Has your probation/parole ever been revoked? *YesNo

Are you currently on court supervision? *YesNo

Are you currently under the supervision of the Idaho Department of Corrections? *YesNo

What is your IDOC number?

IDOC Facility?

Case Manager's Name?

Case Manager's Phone Number

Will you be topping your time? *YesNo

Tentative Parole Date?

If you're involved in any of the above, who do you report to?

Do you have any felony convictions? *YesNo

Please list all felony convictions

Have you been convicted of drug manufacturing or distribution? *YesNo

Have you been convicted of any violent crimes? *YesNo

Please explain:

Are you a sex offender? *YesNo

Are you required to register? *YesNo

Please explain:

Have you ever been convicted of Arson? *YesNo

Do you have any history of violent behaviors? *YesNo

Have you ever attended or are you currently attending anger management classes? *YesNo

Are you currently taking any prescribed medications? *YesNo

What 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. *

SHIP 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. *

Please indicate which, if any, of the following you're involved with: