What best describes your gender?(Required)

Date of Birth(Required)
(Participants must be at least 18 years old)
Current or Temporary Address(Required)
Last permanent residence
County
Is there any reason, based on your past rental history, that you will not be approved for a long-term residential lease?(Required)
Do you have active health insurance?(Required)
Do you have a case manager?(Required)
Do we have permission to contact your case manager?(Required)
Do you have any history of substance abuse or addiction?(Required)
Sobriety Date
Do 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)
Admit Date
Discharge Date
Voluntary or involuntary stay?
Admit Date
Discharge Date
Voluntary or involuntary stay?
Admit Date
Discharge Date
Voluntary or involuntary stay?
Admit Date
Discharge Date
Voluntary or involuntary stay?
Admit Date
Discharge Date
Voluntary or involuntary stay?
Admit Date
Discharge Date
Voluntary or involuntary stay?
Admit Date
Discharge Date
Voluntary or involuntary stay?
Do you have a Criminal History?(Required)
If Yes, are you currently on probation?(Required)
If Yes, do you have any cases pending?
Are you a registered sex offender?(Required)
May we contact this person as a reference?
Are you currently employed?(Required)
Do you have any work restrictions due to a past injury or documented disability?(Required)
Have you ever been employed by KLN, Tuffy’s, IFS, or Kit Masters/Swan Machine?(Required)
Please list your specific personal needs(Required)
Are you capable of all self-care and independent living? (PERHAM 180 does not provide skilled nursing care).(Required)
Are you currently suffering from any injury or medical condition that would prevent you from working?(Required)
Date of most recent physical
Are you currently or will you be applying for SSDI?(Required)
Do you have any mental health diagnosis?(Required)
Date of last mental health evaluation or check-up
Do you currently see a mental health professional?(Required)
Do you have any allergies to food, drugs, or anything else which would require medical attention?(Required)
Please provide two references: Reference 1 Name(Required)
Please provide two references: Reference 2 Name(Required)

Please initial each paragraph to indicate that you have reviewed and understand each component of residing at Perham 180.

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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.

Date(Required)

I authorize Productive Alternatives Perham 180 to conduct a background check as a condition of my acceptance into Perham 180.

Date(Required)

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

Date(Required)