SLE Application

Program of Interest*
Name*
First Last
Phone Number*
Gender*
Date of Birth*
Month
Day
Year
Requested Move in Date*
Month
Day
Year
Pregnant*
Due Date
Month
Day
Year
If applying for Women's & Children, Names and Ages of Children (MAX 2 CHILDREN, MAX AGE 12):
Open CPS Case*
Social Worker Name & Number*
STARS Client*
Recovery Specialist Name & Number
Probation/Parole*
AOR Name & Number
Brief Criminal History (Include Controlling Case if Applicable)*
Sobriety/Recovery Date
Month
Day
Year
Currently in Treatment*
Recent Treatment Completion*
Treatment Provider
Treatment and Substance Use History
Mental Health Diagnosis*
If Yes, List Diagnosis
Mental Health Rx Medications*
If Yes, List Medications
Medical Issues/Concerns*
If Yes, Explain
History of Seizures*
If Yes, Explain
Histroy of Heart Problems*
If Yes, Explain
Medications Other than Mental Health*
If Yes, List Medications
ADA Accommodations (I.E. Walker, Wheelchair, Hearing Aids, Etc.)*
If Yes, Please Explain
Gang Ties*
If Yes, Please Explain
Registration Requirements*
Sex
Arson
Describe any keep away orders, no contact orders, trouble with enemies, etc.*

Treatment and Substance Use History