PATHWAYS HOME REGISTRATION Please fill out the form below. General InformationFirst name(Required)Last name(Required)Date of birth(Required) Month Day Year Gender(Required)MaleFemaleNon-BinaryOtherPrimary contact number(Required)Applicant's number?(Required)Is this the applicant's phone number or a number for someone else?Applicant's phoneOther personEmail(Required) Preferred languageIdioma preferidoEnglishSpanishPortugueseCreoleWho is filling out this application?(Required) Applicant Other (such as caseworker, aftercare, etc.) Applicant (resident) personal email [this is not the caseworker or referral source email address](Required)It is important that this is only the applicant's email address. This is to provide a better communication experience for the guest. Please do not enter an email address that does not belong to the applicant. Referrer email (e.g. caseworker, family member, aftercare coordinator, or other)(Required) Have you ever lived in one of our homes, or have you applied in the past?(Required) Yes No Desired move-in timeline(Required)Immediately (next day or two)Within 3 daysWithin 7 daysWithin 2 weeksWithin 30 daysMore than 30 days from todayWhat is your current address?Please provide your current legal address here. Include the number (apartment # if applicable), street, city state, and zip code. Please note: this may not be the address where you currently live. If you do not have a permanent or legal address, then please indicate this here.How did you hear about Pathways Home?How did you hear about the Pathways Home?(Required)Please select all that apply Referral SoberHouseDirectory.com Google FindHelp.org Facebook Other Social Media Friend or Family Certification Agency Website Grant or Scholarship Funding Source Other Please provide additional details. And if "Other" is selected, please provide more information about how you heard about us:(Required)Desired LocationDesired City/Town(Required)WarehamNew BedfordFall RiverRecovery BackgroundSubstance of choice(Required) Alcohol Opiates Methamphetamine Cocaine Crack Cocaine Cannabis / THC (in any form) Benzodiazepines (benzos) Methadone Buprenorphine Other prescription drug Other street drug Other substance Date of last use(Required) MM slash DD slash YYYY If your substance of choice went by a different name, or you chose any of the "other" options, please add additional details below.Legal History/Criminal BackgroundHave you been convicted of any felonies?(Required) Yes No Please describe the nature of your past felony convictions:(Required)Have you ever been found guilty of a sexual offense?(Required) Yes No If so, please describe the nature of the offense:(Required)Have you ever been convicted of arson?(Required) Yes No If so, please describe the nature of the offense:(Required)Are you currently on probation?(Required) Yes No Probation officer name:(Required)Probation officer phone number:Probation officer email: Please provide any additional information relating to your probation:Are you currently on parole?(Required) Yes No Parole officer name:(Required)Parole officer phone number:Parole officer email: Please provide any additional information relating to your parole:Treatment HistoryHave you ever been in residential treatment?(Required) Yes No If yes, which program or programs were you enrolled in?Please let us know which program(s) that you were in, when you were in them, and for approximately how long.If you are being released from a treatment program, please select from this list. If not, please skip ahead to “Financial Information”. Detox Residential Treatment IOP or Outpatient Treatment Incarceration Other Criminal Justice Program Other Treatment Program Details of the current program:(Such as the name of the program, caseworker's name & contact information [email, phone])Were you in another program previously? Detox Residential Treatment IOP or Outpatient Incarceration Other Criminal Justice Program Other Treatment Program Details of the previous program:(Such as the name of the program, caseworker's name & contact information [email, phone])If you are awaiting a release from jail or graduation from a program, please tell us what that expected date is. MM slash DD slash YYYY Financial InformationPlease describe any and all sources of income which you will use to pay program fees Work Scholarship or Grant Family or Friends SSDI, Social Security, and Other Assistance Other Please describe your work income. Where do you work? How much are you paid?(Required)Put the name of the Scholarshipping or Granting agency and any contact information that you have here.(Required)Please describe the type of assistance from your family or friends. What is the person or people's relationship to you? What are the details of the arrangement? Provide any relevant contact information here.(Required)What is the amount of your assistance income? Is there an end date for this income?(Required)Please provide the details of your other income, including the amount and source details.(Required)Additional InformationPlease tell us anything that would be helpful for us to know when contacting you. You might want to note what phone number or email address (personal or caseworker) is the best means of contact.Terms and ConditionsConsent(Required) I agreeI hereby authorize the Pathways Home and its designated agents to conduct a review of my background including income, housing, treatment, criminal history, or any other public records. I authorize any individual, company, or public agency to release any information, verbal or written, pertaining to me, to VSL or its agents. By submitting this application I am agreeing to the Pathways Home Privacy Policy.Agreed by:(Required)Pathways Home are not clinically monitored or clinical programs and do not offer case management. We do not require bio-psych-social assessments or medical documentation. All information necessary for acceptance will be collected through the phone screen and directly with the Operator of the home. Requests for Reasonable Accommodation: We consider all requests for reasonable accommodations to ensure that our guests can live comfortably and participate fully in our community. If you have a disability and require an accommodation, please inform the Intake Coordinator assigned to your application. We are here to support your recovery journey and will work with you to address your needs.
