Rapid Application Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Who We Serve Our housing program is structured as a men’s-only residential program for adult men. Because of our current facilities and program design, we are not able to provide residential services for women. Whenever possible, we will try to refer women to other programs that may better meet their needs. Name *FirstLastAn asterisk * indicates an entry is requiredDate of Birth:MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Primary Phone Number: *Either self or family memberPrimary Email:Either self or family memberSSN:Race/Ethnicity:CaucasianHispanic/LatinoBlack/African AmericanNative American/Alaskan NativeNative Hawaiian/Pacific IslanderAsianBi RacialOtherLanguages Spoken:Are you a veteran? *YesNoHOUSINGWhat counties are you applying for? Prices are program fees per month for the respective counties.Pierce – $700.00King – $700.00Whatcom – $650.00Spokane – $600.00Yakima – $550.00Grays Harbor – $600.00ADA Compliant Housing Needs? *YesNoFunding Source *Self PayAgencySSIDOC VoucherFamilyNoneOtherHave you ever applied to HOM in the past?YesNoIf yes, when? Include month and year.CRIMINAL HISTORYIf the applicant is not currently incarcerated, feel free to advance to Section B.Are you currently on DOC supervision? *YesNoDOC #:List all criminal history (NA if none) *Please complete the application to the best of your abilities and be thorough and honest. Please note, we are looking for an honest and complete disclosure of all criminal history. Your criminal history will not cause you to be denied, however withholding information will be grounds for denial of application.Security Threat Group/Gang Affiliation *YesNoISRB: (Intermediate Sentencing Review Board) *YesNoSex Offender Level (if applicable)123TBD/UnknownCURRENT STATUSThis applies to the applicants who are not currently incarcerated, even if you have previous felony convictions.Relationship with the applicantDepartment of CorrectionsCase WorkerAttorneyFamilyOtherComplete if someone other than the applicant is filling out this application.Current living situationGive a brief explanation of your current living conditions, whether it be homelessness, living with a friend, out of your car or otherwise. Please include the city you reside in.If accepted, what is your ideal move in date?HEALTH & MEDICAL HISTORYDo you have medical conditions? *YesNo*If yes, please describe: Do you have any history of mental illness? *YesNo*If yes, please describe: Are you currently under the care of a mental health counselor or therapist?YesNoIf in counseling or therapy, please briefly explain why.Have you ever abused drugs or alcohol?YesNo*If yes, please describe: Prior substance use disorder treatment?YesNoList all prescribed medication and the reason for those medications.HOUSE OF MERCY – CLEAN & SOBER HOUSING PROGRAM STIPULATIONS AGREEMENTStipulated Agreement: Please read and check off each of the following stipulations as an indication of agreement. If accepted in the program, you will be expected to sign a document similar to this. I, (type name below)hereby acknowledge that House of Mercy is a faith based, clean and sober housing program. Upon my acceptance into the Clean and Sober Program, I agree to comply with all the following terms of participation; failure to do so could result in my immediate termination.PROGRAM REQUIREMENTS *I understand my participation is for a minimum of THREE MONTHS. (Long term participation is available)I understand that if I am on the DOC Voucher program, once the vouchers expire, I may be required to move to a different house within the clean and sober program at the discretion of Ministry Staff.I agree to participate in all required HOM program meetings. Any required meeting missed must be approved in advance, by the House Leader/ Staff. For new arrivals to HOM, this includes the mandatory first 4 Sunday evening meetings, weekly house meetings, as well as the ELEVATE Orientation Class, and first week of Foundations classes (makeup meetings are available).I agree to follow all HOM rules (curfews, Chores, room standards, meetings, etc). Failure to do so will lead to additional stipulations implemented by HOM Staff. Failure to follow these additional stipulations can result in a discharge from the program.PROGRAM POLICIES *I understand my clean and sober housing is contingent upon my active participation and compliance to all program stipulations contained herein and that Landlord/Tenant rights do not apply. I understand if I self-terminate or am terminated there will be no refund of Clean& Sober Housing Program Fees and I must leave the premises immediately upon request.I understand if I self-discharge or am discharged, I must take all my belongings with me within 48 hours. Anything left becomes the property of House of Mercy, and may be immediately disposed of, unless otherwise agreed upon in writing by HOM Administrative Staff.I understand I may be discharged immediately for NON-PAYMENT AND/OR LATE PAYMENT OF PROGRAM FEES, INSUBORDINATION, A THREAT OF VIOLENCE, POSSESSION OF WEAPONS, PROPERTY ABUSE, LYING, STEALING, PORNOGRAPHY, OR BEING INVOLVED WITH ANY ILLEGAL ACTIVITY.Under no circumstance are non-prescribed drugs, alcohol or THC to be on the premises, possessed or consumed. The House Leader is to be informed of all prescribed drugs. Under no circumstances am I to give and/or share any prescribed drugs. Arrangements for possession and distribution are to be made with HOM Staff and House Leader.I consentto submitto urinalysis and/or breathalyzer tests, at the discretion of the HOM Staff or House Leader, to determine whether I am under the influence of illegal drugs and/or alcohol or THC while on any properties managed by the HOUSE OF MERCY. I understand that the results of these tests will be reviewed and evaluated by ministry staff. If the test results indicate that I am under the influence of alcohol or illegal drugs, or that the sample was altered, I further understand that HOUSE OF MERCY may, at its sole discretion, discharge me from the Program or put me on a revised set ofstipulations. Finally, I understand that failure to submit to the above-described testing upon request of HOUSE OF MERCY staff may also result in termination from the Program.I understand that overnight stays are permitted providing CCO approvals and notification given to the house leader 24 hoursin advance. Additionally, I understand that I’m required to sign the Overnight Notification sheet and may be subject to drug testing upon return from any overnight stays.I understand there are to be no unapproved guests. I willseek approval from the House Leader prior to inviting guests onto the premises. At no time are minors allowed on the premises of our S/O designated housing. I also understand that sexual activity is not permitted on the premises.I understand pets are not allowed; this includes service animals.I understand that House of Mercy is not ADA equipped or Assisted Living HousingI will maintain orderly & sanitary living conditions. If there is more than one occupant in my room, all must share equally in maintaining these conditions. Cleaning responsibilities are to be agreed upon by those occupying the same living area. If agreement is not reached or the premises is not maintained in a neat, sanitary condition, the House Leader will assign duties, so sanitary living conditions are maintainedI agree to maintain healthy hygiene practicesto include regular showers, hand-washing, and dental hygiene.I understand that if I am absent from HOM 72 hours or more without permission I will be discharged from the program for abandonment.I understand that House of Mercy may request a release of information form from the Department of Corrections and/or any other program/treatment provider/employer to release any and all records, to be reviewed by the House of Mercy staff; to include, but not limited to medical/mental health/therapy reports, financial and employer performance reports for purpose of making informed decisions regarding the client.I agree not to hold House of Mercy responsible for any injury occurring on or off properties owned, maintained, used, or leased by House of Mercy.I understand that all internet capable devices are to be utilized only by the owner and that they are not to be sold, traded, borrowed, bartered, shared, loaned or accessed by any HOM client other than the owner of the device.All Program Fees are due on the 1st of each month for the current month. Any payment received after the 5th of the month is past due, and a $25 late fee will be imposed.I understand if I’m put on a payment plan or get behind on my program fees, I am required to take Financial Freedom classes.I agree to give House of Mercy Staff a 30-day written notice prior to vacating. If I move prior to the 30 days, or fail to give notice, I will be responsible for the current month’s program fees, if not paid, and will forfeit any paid program feesI understand if I have an unpaid balance to HOM and do not make satisfactory payment arrangements, my account may be placed with an external collection agency.I authorize HOM and its collection agency to contact me via phone, text, email, or mail using the information I provide, including automated methods. I also consent to the collection agency sharing my account details with third parties for communication purposes.I understand that House of Mercy is not liable for any damage to my property. This includes but is not limited to personal items such as electronic devices, cash, vehicle damage, or any other participant owned property. House of Mercy is not obligated to reimburse for any damages, or responsible for “making it right”.PATHWAYS *I agree that if I receive A MAJOR violation, or THREE MINOR VIOLATIONS in a 6 MONTH period, I will be required to complete House of Mercy’s DIVERSION PATHWAYS (as follows) to remain in the program.I understand that if I relapse (alcohol, drugs, pornography, etc.) that I will be required to attend the HOM class for Overcoming Addiction to continue in the programI understand that if I get behind in my program fees (fees not paid in the month they are due, multiple pay plans, etc.) that I will be required to attend the HOM class for Financial Freedom.I understand that if I am able to work and still am unemployed or become unemployed after the 90-day mark, I will be required to attend the HOM class for Work Life skills. This may also include participating in or working for Redemption Services until employed.I understand that If I receive a major violation while in the program (multiple room issues, chores, hygiene or other stipulation fails) I will be required to attend the HOM class for Personal Development.Date / TimeDateTimeSignature – By signing below, I certify that the information provided in this application is true and complete to the best of my knowledge, and I agree to abide by the terms and conditions stated above. *Submit
