Name *

First Name

Last Name

Ethnicity *

Non-Hispanic/Non-Latino

Hispanic/Latino

Phone Number *

(###)

###

####

Type of Addiction *

Check all addictions that apply

Alcohol

Drugs

Nicotine

None

Are you on Medications? *

Yes

No

Do you have HIV, Hepatitis A, B, or C, TB, Shingles, Scabies, SARS (Covid-19) or any other communicable disease? *

Yes

No

Do you receive any benefits (SSI, Retirement, etc.?) *

Yes

No

Are you a Veteran? *

Yes

No

Do you receive Benefits from the VA? *

Yes

No

Have you been convicted of a felony? *

Yes

No

Have you been charged with a sex crime? *

Yes

No

Are you on Probation/Parole? *

Yes

No

Have you received any Homeless Benefits (housing list, free healthcare, etc.) *

Yes

No

I understand that after submitting this form, I am not promised an interview or placement on the waiting list. I understand that if my application is approved, someone will contact me to set up an interview where I will receive a Program Policy for my review. *

Yes, I understand

I do not understand

By submitting this form, I affirm that all the information I have given is true and correct. I affirm that I have filled this out myself and am personally requesting an interview for the LTP Program. *

Yes, I affirm

No