DRRMS

Application Source

How is this application being submitted?

1. Applicant Information

Full legal name

Preferred name

Date of birth

Phone

Email

Requested move-in

Current address

City / State / ZIP

Last four of SSN

Driver License / State ID

Documents Available

Photo IDSocial Security CardBirth CertificateNeed help obtaining documents

Identification Status

I currently have a government-issued photo IDI need assistance obtaining or replacing identificationI do not currently have identification

Identification upload is optional. If you have identification available, you may upload a copy to assist with application review. Uploading identification is not required to submit an application. Dignity Restored can assist applicants who need help obtaining identification.

Optional identification upload (PDF, JPG or PNG; maximum 5 MB)

2. Current Housing Situation

Current housing situation

How long without stable housing?

Current place you are staying

Prior transitional/recovery/shelter program?

Why are you seeking transitional housing now?

Prior program / dates / reason for leaving

3. Employment, Income & Benefits

Employment status

Employer / position

Work schedule

Monthly employment income

Total monthly income

Able to pay $875 monthly?

Able to pay $875 deposit?

Benefits / Other Income

Job skills / work experience

Employment / stability support requested

4. Legal & Supervision Information

Most recent facility / release date

Pending charges / explanation

Probation / parole / supervision

Officer / agency / phone / next report

Sex-offender registry requirement?

Court/reporting/legal restrictions affecting participation

A history of incarceration does not automatically disqualify an applicant. Legal information is used for eligibility, placement, safety planning and supervision coordination.

5. Health, Medication & Accessibility

Safety-related medical information you voluntarily want staff to know

Prescribed medication / purpose (optional)

Allergies (optional)

Disability / accessibility need?

Requested reasonable accommodation

Help connecting with medical / mental-health / counseling services?

6. Substance Use & Recovery Support

Willing to live where drugs/alcohol may not be possessed or used on property?

Current treatment/counseling/recovery/peer support

Program / provider

Willing to participate in screening when required by written policy?

What support would help you remain stable?

7. Transportation, Vehicle & Emergency Contact

Transportation Used

Vehicle make (if parking a vehicle)

Vehicle model

Vehicle color

License plate number

Emergency contact name

Relationship

Emergency contact phone

Emergency contact email

May Dignity Restored contact this person in an emergency?

8. Personal Goals

Goals for first 30 days

Goals for full program

Primary goals — one per line

9–10. Financial & Important House-Rule Understanding

Standard monthly bed fee: $875. Standard deposit: $875, separate from the monthly bed fee. Authorized Directors may approve different rates, proration, sponsorship, payment arrangements or full/partial waivers. Curfew is 11:00 PM every night. No unauthorized guests. Drugs and alcohol may not be possessed or used on the property. Residents use sign-in/out, complete household responsibilities, attend required meetings and work toward an approved Stability Plan.

Acknowledgments

I understand the standard $875 monthly bed fee and separate $875 deposit.I understand the important house-rule notice above.I will promptly notify staff if I expect difficulty paying.

11–12. Screening Authorization & Release of Information

Authorization

I authorize screening reasonably related to eligibility, safety and placement.I understand authorization does not guarantee acceptance.

People / Agencies Dignity Restored May Contact

13. Applicant Certification & Electronic Signature

Electronic signature — type your full name

Signature date

Online status access: Create a 6-digit PIN. After submission, use your DRRMS application number and this PIN to check your application status. Keep your PIN private.

Create 6-digit PIN

Confirm 6-digit PIN

Certification

I certify that this application is true and complete to the best of my knowledge.I have read this application or had it explained to me.