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1 Step 1

New Beginnings Program Application

You should receive a call back within 2 business days of submission. 

If you are in need of emergency shelter, call United Way's Help Line 2-1-1.

Name (First and Last)your full name
Date of Birth
Phone number (if available)
New Beginnings is a smoke-free program. Are you willing to comply with this policy?
YesNo
I agree to not smoke.
Are you currently in any danger (i.e. domestic violence)?
YesNoOther
Please describe your current living situation (where did you sleep the last few nights and where will you sleep tonight)?more details
0 /
Are you a U.S. citizen?
YesNo
Which documents do you have in your possession?pick one!
What I mean by "other"more details
0 /
Are you currently pregnant?
YesNo
How many children (under the age of 18) will accompany you in this residential program?
Are all your children walking, potty-trained and current with immunizations?choose all that apply
Please list the age and gender of any child you desire to accompany you in our program:more details
0 /
Are you currently employed?choose all that apply
If employed, how many hours do you work each week?your full name
If employed, what is your hourly wage?your full name
Is anyone that you are applying for currently disabled?choose all that apply
Have you been denied for disability benefits?choose all that apply
Do you currently have any long term medical conditions?choose all that apply
If you said yes, please list the conditions here:your full name
Are you currently taking any medications?choose all that apply
If you said yes, please list the medications here:your full name
Do you have any current drug or alcohol use?choose all that apply
If you said yes, please tell us more:your full name
Do you have a history of drug, alcohol or prescription medication addiction?choose all that apply
If you said yes, please tell us more:your full name
Any history of drug and/or mental health treatment?choose all that apply
If you said yes, please tell us more:your full name
Have you ever been arrested?choose all that apply
Details of my arrest (charges, date, conclusion):more details
0 /
Are you required to register as a sex offender or predator?choose all that apply
Why do you feel you will benefit from our housing program?more details
0 /
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