Rental Form - Transitional Notify TRANSITIONAL RENTAL APPLICATION (1 per applicant) Non-Refundable Fee: $25  THE PROPERTY – HOT Pets: YesSmoking Allowed: No Parking Space: Yes Start Date: LANDLORD'S DETAILS Name: House of TransformationAddress: 3327-D Fairbanks street Anchorage, AK 99503Telephone: (907) 333-2468E-Mail: admin@houseoftransformations.comAPPLICANT DETAILS First NameMiddle NameLast NameAlternate NameDate of Birth:Email:SSN:Phone:Consent to contact I consent to be contacted by House of Transformation via SMS, email, or phone using the information I provided for the purposes of reviewing my application.DemographicsSex Assigned at Birth- Select -MaleFemaleIntersexDecline to respondOtherGender Identity- Select -MaleFemaleTransgender Male / Transman / FTMTransgender Female / Transwoman / MTFGender QueerNon-binaryDecline to respondOtherWhat is the highest level of education you completed?- Select -Elementary or High school, no diplomaElementary or High school7th Grade7th Grade, GED8th Grade8th Grade, GED9th Grade9th Grade, GED10th Grade10th Grade, GED11th Grade11th Grade, GEDHigh school diploma12th Grade GED12th Grade (no diploma)College degreeCollege, no degreeUndergraduate/Graduate DegreesAssociate's degree, vocationalAssociate's degree, academicBachelor's degreeMaster's degreeProfessional degreeDoctorate degreeOtherWhat is your primary language?- Select -EnglishSpanish or Spanish CreoleFrench (including Patois, Cajun)French CreoleItalianPortuguese or Portuguese CreoleGermanYiddishOther West Germanic languagesScandinavian languagesGreekRussianPolishSerbo-CroatianOther Slavic languagesArmenianPersianGujarathiHindiUrduOther Indic languagesOther Indo-European languagesChineseJapaneseKoreanMon-Khmer, CambodianHmongThaiLaotianVietnameseOther Asian languagesTagalogOther Pacific Island languagesNavajoOther Native North American languagesHungarianArabicHebrewAfrican languagesOtherQuestionsAre you affiliated with and/or have shares in a Native Corporation?Program Cost Transitional Housing beds are $22.50 to $27/night depending on intake criteria (you will be notified of your daily rate upon approval / acceptance into program). How will you pay for the program ? I will pay myself Someone else will pay Insurance will pay I need financial assistance Vouchers - Federal Vouchers - State Vouchers - County Vouchers - Other Scholarship OtherProgram DetailsDo you have any concerns with sharing a room? Yes NoAre you able to perform household chores? Yes NoPersonal Contacts (Family)What is your marital status?- Select -SingleMarriedEngagedDivorcedSeparatedDomestic PartneredWidowedAre you fleeing a domestic violence situation? Yes NoAre you in the process of family reunification? Yes NoDo you have children? Yes NoSubstance Use HistoryDrug(s) of ChoiceAlcoholAmphetaminesBarbituratesBath SaltsBenzodiazepinesBuprenorphineCocaineEcstasy (MDMA)FentanylHeroinInhalantsK2KetamineKratomMethadoneMethamphetamineMorphineNicotineOpiatesOxyPCPPsychedelicsTCATHCWellbutrinGabapentinXylazineMetonitazeneMuscle RelaxersAplha-PVP (Flakka)What were the last drugs used and when?For how many years have you been using alcohol and/or drugs? (Years)Do you use tobacco? Yes NoMedicalDo you have any allergies? Yes NoDo you have any physical health / medical conditions or disabilities? Yes NoDo you have any upcoming appointments or ongoing physical needs? Yes NoMental HealthDo you have any mental health issues or diagnosis? Yes NoHave you ever experienced any suicidal ideations, attempts, or received in-patient treatment for self-harming behaviors? Yes NoDo you have an Eating Disorder or Body Image Disorder? Yes NoDo you have a need for mental health services? Yes NoHave you ever been a victim of sex trafficking? Yes NoAddictive BehaviorsDo you identify patterns in other areas of your life that may have some addictive qualities? None Internet Food Relationships Money Shopping Sex OtherCommunicable DiseasesAre you at risk for exposure to any communicable diseases, or have you been in contact with someone who has? Yes NoAre you experiencing shortness of breath, coughing, fever, or other symptoms of Coronavirus and/or a flu? Yes NoHave you traveled outside of the country in the last 30 days? Yes NoMedicationsAre you currently using any prescription medications? Yes NoAre you currently using any over-the-counter medication? Yes NoAre you participating in or about to enter MOUD or MAT services (drug replacement programs)? Yes NoTreatment HistoryAre you currently in a treatment program? Yes NoHave you ever been through any other treatment programs previously? Yes NoRecoveryWhat is your Sober or Clean date?Do you have a Sponsor? Yes NoAssistance & HelpDo you have a learning disability or difficulty reading? Yes NoDo you have any immediate needs such as clothing or toiletries? Yes NoDo you need help to renew any forms of identification? Yes NoDo you need assistance with any food programs? Yes NoCourts & Criminal JusticeAre you currently involved in any legal proceedings or criminal justice issues? Yes NoDo you have a requirement for Community Service? Yes NoDo have any court ordered treatment requirements? Yes NoDo you have any pending sentencing or possible jail time upcoming? Yes NoHave you ever been charged or convicted of abuse or neglect of any person, including but not limited to disabled person, senior, or child? Yes NoAre you affiliated with any gang? Yes NoRestrictionsSelect all legal requirements that apply None Applicable House Arrest Probation Parole Drug Court In Prison OtherAre you required to register as a sex offender? Yes NoAre there any Restraining Orders against you or by you? Yes NoAdmissionsDate / TimeDo you have a personal relationship with anyone that works for House of Transformation? Yes NoAre there any issues that could prevent you from completing the program? Yes NoClient StatementWere you referred to House of Transformation? Yes NoPlease describe what issues led you to seek housing with House of Transformation. Be specific as to details such as how, when, where and your personal responsibility.What are your goals and expectations?EmploymentAre you able to work? Yes NoAre you currently employed? Yes NoAre you willing to work 40 hours a week of gainful employment? Yes NoPersonal FinanceIf for some reason you cannot pay rent per week / month who can you call upon to help you?Do you receive any ongoing financial reimbursement for any reason? Yes NoTransportationDo you have a valid drivers license? Yes NoWhat is your primary mode of transportation? Personal Vechile Family / Friend Public TransitDo you plan on having your personal vehicle at the property? Yes NoDo you have proof of registration? Yes NoDo you have proof of insurance? Yes NoSensitive InformationSocial Security NumberAdditional InfoPlease enter any other information about yourself or your situation that you feel we need to knowSubmit Form
