Application – Rise to New Freedom

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Supportive Housing Intake Assessment

Become a Waitlist Member

Client Name

Date of Birth

Gender

Race

Client Contacts

Email

Current Living Situation

Representative Name

Representative Organization

What type of room do you prefer?

Private Shared

When do you need placement?

How will the client pay?

What is your monthly income?

Does the client suffer from mental illness?

Yes No

What is your diagnosis?

Are you on medications?

Yes No

list them

Are you disabled?

Yes No

Does the client requiere a handicap accessible living environment?

Yes No

Is the client an sex offender?

Yes No

Have you been convicted as a sex offender(your answer to this question won't disqualify you form our program and services)

Yes No Yes, with 1000 ft restriction Yes, without 1000 ft restriction

Are you currently on probation or parole?

Yes No

Please give your probation/parole officer's name and contact.

Do you currently need help with recovery from opioids and others drugs or alcohol?

Do you have any children moving in with you?

Yes No

Please mention their age

Select all the services you need:

Transportation assistance job placement Apply for SNAP benefits Apply for SSI/SSDI Organization payee Health Insurance enrollment clothing donation cell phone/tablet assistance group therapy Day program Life skills/recovery group

How did you hear about us?

Referral newspaper social media search engine/web word of mouth

At New Freedom, we understand that seeking help is the first courageous step on the road to recovery.

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Contact Info

763.220.5483
763.220.3969
referrals@newfreedominc.com
3162 90th Ave, Princeton, Minnesota 55371.

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