Peaceful Knights Transitional Living Program Application (to be filled out by applicant only)
This is part 1 of a 2 part intake process.  Please complete this part and someone will reach out to you to schedule the 2nd part in person or  to gather more information.  If accepted, please remember that this program requires the following:  1) pass a 13 screen drug test, 2) must attend church every Sunday morning, 3) must be in by 10pm unless working  past that time, 4) must pay $100/week rent once you find employment, 5) must help keep the property clean, etc.  
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Peaceful Knights
Name *
Telephone number: *
What town are you currently in? *
If you are not in Carbon County, did you ever live in Carbon County?  If so, what address? *
How old are you? *
How did you hear  about us? *
Are there any children with you/in your custody? *
Do you have any PFAs against anyone? *
Are there any PFAs currently against you? *
Are you able to work 40 hours per week and climb stairs and walk long distances? *
Have you applied for disability in the past 5 years?   *
If so, what is your disability ?
Are you currently collecting SSD or SSI?  *
If so, how much do you receive per month?
Are you currently collecting Food Stamps?  If so, how much do you receive/month? *
Are you currently employed?   *
if so, how much is your average monthly income? (take home)
Do you own a vehicle?  If so, what is the year/make/model? *
Do you own a house/motorcycle/other assets?  If so, please list *
How long have you been homeless? *
Where did you sleep last night? *
How many times have you been homeless in the past 5 years? *
Are you a Veteran?  If so, which branch? *
Are you unemployed?   If so, for  how long? *
If you are not unemployed, where do you work?
Which of the following have you been diagnosed with? (check all that apply) *
Required
Please list your current medications and what each is prescribed for *
How often do you have suicidal thoughts? *
Are you currently experiencing a domestic dispute (fight with your significant other)  If so, please explain *
Have you been the victim of  domestic violence in the past 5 years?  If so, please explain *
Can you pass a 13 screen drug test today? *
Which of  the following do you struggle with (currently or in the past) Please check all that apply *
Required
Do you have a medical marijuana card? *
Do you agree to random drug and alcohol testing if you should be accepted into the program? *
Have you ever been to a rehab?  If  yes, please provide details: location, how long were you there, did you complete satisfactorily, what was your addiction? *
Do you have a criminal background?  If so, please provide details:  How many felonies?  What were they for?   *
Have you ever had any sex offenses?  If so, are you on the Megan's law website? *
Please list 2 towns/cities that you have lived in? *
Who is your emergency contact? *
What is their relationship to  you? *
What is their phone number? *
Do we have permission to contact them for more information? *
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