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Bio
Contact Us
(301) 979-2413
(301) 979-2413
Home
Services
Bio
Contact Us
Home
Services
Bio
Contact Us
Intake Form
Month to month Agreement Form
Rules & Policy
Payment Form
Rules & policy addendum
Applicant Full Name?
Applicant Phone Number?
Applicant Email?
Application Date?
What is your desired location?
Hyattsville, MD
Other:
Who referred you? How did you hear about us? Kindly put name of person/agency and phone number.
Who Is The Application for?
Choose
A client (I am a - Case worker, referral agency, social worker or sponsor)
Myself
Family Member
Gender?
Male
Female
Others
Date Of Birth
Age?
Preferred Move In Date?
What is your budget?
Which type of room would you prefer?
Private Room
Shared Room
Any
Are you aware that this is a shared living home?
Choose
Yes
No
Have you lived in shared housing before?
Choose
Yes
No
Are you coming from another group home? If yes, please specify which one and for how long you've been living there and the reason for leaving.
Current Address?
How long would you like to be a resident of our home?
Choose
1-3 Months
4-6 Months
7-12 Months
1-2 Years
Criminal History
Choose
Yes
No
If yes, please provide details of any criminal charges or convictions you have, including the nature of the charges and any associated legal outcomes.
Funding Source
Self Pay
Voucher
Social Security Insurance
Social Security Disability Insurance
Government or State Organization
Non Profit Organization - Rent Assistance
If you've received a voucher, what is the voucher's name? Write "N/A" if this doesn't apply.
Are you Employed?
Choose
Yes
No
If you are employed, what are your hours/shift and what city do you work in? (If not applicable, please put N/A)
If you are employed, name & address of employer? (If not applicable, please put N/A)
What is the monthly income that you receive?
What is the specific date that your payment is disbursed?
Any additional Income Information e.g. Part-time job?
If you are not employed, do you intend to apply for a job within 1 month of your arrival in Trusted Oasis ?
Choose
Yes
No
If you don’t intend on working or going to school, etc. explain why not and what you plan on doing with your daytime hours?
Are you pregnant?
Choose
Yes
No
Please disclose any existing medical/mental conditions or health concerns that we should be aware of. What have you been diagnosed with, if any?
Do you have any food or drug allergies? If yes, please elaborate.
Are you currently attending Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings? If yes, please specify which one(s). If no, do you need to find a meeting to attend? If this doesn’t apply, write N/A
Are you currently taking any medications?
Yes - Prescription medication
Yes - Over the counter medication
No
Are you currently taking any medications as part of your recovery treatment?
Choose
Yes
No
Are you involved in any other support groups or programs related to recovery? (If this doesn’t apply, write N/A)
Have you completed any rehabilitation or treatment programs? If yes, please provide details. If this doesn’t apply, write N/A
Do you have a history of relapse? If yes, please provide details and specify if you have a relapse prevention plan in place.
Do you have a sponsor or are you/will you be actively seeking one? (Please specify) If this doesn’t apply, write N/A
Do you have any specific needs or requirements related to your recovery journey that you would like us to be aware of?
Make Appointment
