If you have questions or issues completing the online form below, please email hannahf@productivemn.org I (type name below) would like to apply to be a participant in the PERHAM 180 program.(Required) What best describes your gender?(Required) Male Female Prefer Not to Say Other Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920(Participants must be at least 18 years old) Current or Temporary Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Email(Required) Last permanent residence City State / Province / Region County CountyHow long did you live here? Is there any reason, based on your past rental history, that you will not be approved for a long-term residential lease?(Required) Yes No If you answered yes above, please explain Do you have active health insurance?(Required) Yes No If you answered yes above, who is your health insurance provider? Do you have a case manager?(Required) Yes No If you answered yes above, what is your case managers name? Case Manager's Phone NumberDo we have permission to contact your case manager?(Required) Yes No Do you have any history of substance abuse or addiction?(Required) Yes No If you answered yes above, chemical(s) of choice: Sobriety DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do you have a history of Chemical Dependency outpatient or inpatient treatment? If Yes, please list below all inpatient, outpatient, and halfway house admissions and discharges for the past two years, along with whether it was a voluntary or involuntary stay.(Required) Yes No Admit DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Facility Discharge DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Voluntary or involuntary stay? voluntary involuntary Admit DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Facility Discharge DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Voluntary or involuntary stay? voluntary involuntary Admit DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Facility Discharge DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Voluntary or involuntary stay? voluntary involuntary Admit DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Facility Discharge DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Voluntary or involuntary stay? voluntary involuntary Admit DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Facility Discharge DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Voluntary or involuntary stay? voluntary involuntary Admit DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Facility Discharge DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Voluntary or involuntary stay? voluntary involuntary Admit DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Facility Discharge DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Voluntary or involuntary stay? voluntary involuntary Do you have a Criminal History?(Required) Yes No If you answered yes above, please explain If Yes, are you currently on probation?(Required) Yes No If Yes, do you have any cases pending? Yes No Are you a registered sex offender?(Required) Yes No Name of Probation Officer Probation Officer Phone NumberMay we contact this person as a reference? Yes No Are there any other legal concerns that we should be aware of? (commitment, revocation of driving privileges, recent arrest, warrants)? Are you currently employed?(Required) Yes No If yes, list the name and address of your current employer.Approximately how many hours a week do you currently work?If not currently working, how many hours a week are you willing or able to work?Do you have any work restrictions due to a past injury or documented disability?(Required) Yes No If you answered yes above, please explain Have you ever been employed by KLN, Tuffy’s, IFS, or Kit Masters/Swan Machine?(Required) Yes No If you are not currently employed, please provide your most recent employment and reasons why you are no longer workingPlease list your specific personal needs(Required) Job Coaching Medication Management Daily Living Skills Budgeting Crisis Skills Sobriety Health/ Wellness Transportation Social Skills/Communication Other If “Other”, please list the type of help you need Describe your source of transportation to and from work, appointments, meeting, etc. Are you capable of all self-care and independent living? (PERHAM 180 does not provide skilled nursing care).(Required) Yes No Are you currently suffering from any injury or medical condition that would prevent you from working?(Required) Yes No If yes, please explain the injury illness or medical condition and how it affects your ability to work: Date of most recent physicalMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you currently or will you be applying for SSDI?(Required) Yes No If yes, please explain Do you have any mental health diagnosis?(Required) Yes No If yes, please explain Date of last mental health evaluation or check-upMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do you currently see a mental health professional?(Required) Yes No If yes, please provide provider(s) name and locationDo you have any allergies to food, drugs, or anything else which would require medical attention?(Required) Yes No If yes, please explain Please describe in your own words why you feel you are a good candidate for Perham 180 Program:Please describe in your own words what “SUCCESS” looks like for you over the next six months:Please describe how you plan to implement actions needed to achieve the goals you have set for yourself:Please provide two references: Reference 1 Name(Required) First Last Relationship to Reference 1(Required) Reference 1 Phone(Required)Please provide two references: Reference 2 Name(Required) First Last Relationship to Reference 2(Required) Reference 2 Phone(Required) Please initial each paragraph to indicate that you have reviewed and understand each component of residing at Perham 180. I understand that residence at premises of the PERHAM 180 is a central component of the Program. I understand that I am a licensee of PERHAM 180 and Productive Alternatives, Inc., and not a tenant. I understand that I am not signing a lease, PERHAM 180 and Productive Alternatives, Inc., is not my landlord, and residency at the PERHAM 180 premises will at no time confer tenancy rights. PERHAM 180 and Productive Alternatives, Inc., may terminate your residency for violation of this Agreement.(Required) Type initials hereI understand that there is no use of illegal drugs or alcohol in my room or on the premises. Any use may result in my dismissal from the program.(Required) Type initials hereI understand if I sell or provide drugs or alcohol to a fellow Perham 180 resident, this will result in immediate dismissal from the program and possible legal consequences(Required) Type initials hereI understand that as part of this application, I will need to sign an authorization, consenting to a criminal background check. If I have a history of sexual predatory offences or violent crime offenses or if I have an open criminal case I may not qualify for the program(Required) Type initials hereIf I am accepted as a participant in the program, I agree to work with the program team who will assist me in developing and carrying out an individualized plan which will meet my personal needs. Depending on my needs, my plan may address mental health issues, sobriety, obtaining and retaining employment, obtaining permanent housing, and independent living skills(Required) Type initials hereI understand that the PERHAM 180 only provides temporary housing. A participant may live in the transitional housing for a period not greater than 8 months. I understand that depending on my plan and circumstances, I may live in the PERHAM 180 a shorter time period, moving out prior to the end of eight months.(Required) Type initials hereI understand that participants will need to work with the program team to find employment, if not already working. Once employed, I need to maintain employment, or I may be asked to leave the program.(Required) Type initials hereI understand that participants will need to find and secure more permanent housing and work with the program team towards this goal.(Required) Type initials hereI understand that participants will accept services from several different providers including but not limited to; Productive Alternatives job coaches, community support programs, day treatment programs, case management providers, Adult Rehabilitative Mental Health Service providers and recovery support services such as Alcoholics Anonymous, or Narcotics Anonymous(Required) Type initials hereI understand that that participants will have an individualized plan and will need to work with providers to develop independent living skills which could include lessons on budgeting, grocery shopping and cooking, cleaning and household management, use of community resources and public transportation, time management, planning and scheduling, and personal hygiene and self-care.(Required) Type initials hereI understand that participants may be asked to leave the program in order to address issues identified by their program team and remittance into the program will be at the discretion of the program team and based on availability.(Required) Type initials hereI understand that participants, can quit the program at any time, but will not be able to reapply to the program for up to one-year(Required) Type initials hereI understand that sometimes, due to issues like housing space, job availability or transportation, a person qualified to participate in the program may be put on a waiting list for this program, and/or if the program team deems it appropriate, may be referred to a different agency that provides a similar type of service(Required) Type initials hereI understand that if my application is accepted and I qualify for admittance into the program I will need to meet with the PERHAM 180 Coordinator. During the meeting the coordinator will obtain information about me, to determine what services I may be eligible for and to begin my programming plan.(Required) Type initials hereI understand that all participants will need to attend an orientation meeting prior to moving in. At orientation all participants will review program policies, review, and sign the program agreement, provide emergency contact information and sign all necessary releases.(Required) Type initials hereI understand that participants residing in PERHAM 180 housing program will need to sign a program agreement and will need to abide by the terms of that agreement to live in the provided housing. I acknowledge that a copy of the agreement is attached to this application and that I have reviewed it.(Required) Type initials here Please sign by typing your full legal name where indicated below: By signing this, I verify that the statements in this application are true. I authorize the use of the information and contacts to complete the reference checks. I understand that if I provided false information or did not complete the application that my application may be rejected. If my application is accepted, I understand that I will have to sign an authorization for a criminal background check. Signature(Required) Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 I authorize Productive Alternatives Perham 180 to conduct a background check as a condition of my acceptance into Perham 180. Signature(Required) Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 I hereby consent to a two-way exchange and release of information contained in my case file including admission, treatment, and discharge planning between (current facility and staff) and Productive Alternatives Perham 180 Signature(Required) Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CAPTCHA Δ
