Application for Erie Housing Sober Living Program

Name * Required

Email Address * Required

Phone Number * Required

Gender * Required

We currently only house individuals. Do you need housing for children? * Required

Do you have a vehicle? * Required

We cannot accept any animals in the home. Do you have any service animals or pets? * Required

Please tell us a little bit about yourself and your situation * Required

Feel free to add any additional information you feel is relevant to your admission into the Erie Housing Independent Shared Living program.

Are you okay with a shared bedroom? There are no bunk beds. Private rooms are very limited. * Required

This is a community living situation in a home with multiple people. We don't have individual apartments. Are you okay living in a group situation? * Required

Are you a Veteran? * Required

Do you have a case manager or parole officer or an individual who is in charge of your treatment?

Please add the contact details for any agency personnel, case managers, or social workers you regularly work * Required

If none, write "None"

We use room license agreements, not leases. You could be removed immediately for breaking the rules of the house or causing disturbances. Please acknowledge that you understand this. * Required

All of our houses are sober living homes. Alcohol, marijuana, and illegal substances are not allowed on the property, and anyone caught with them will be immediately removed. Please acknowledge that you understand this. * Required

Are you able to prepare and eat food on your own? * Required

Are you able to get in and out of bed and move around freely on your own? * Required

Are you able to manage your own health care? * Required

Are you able to maintain your own personal hygeine? * Required

Are you able to do your own laundry? * Required

Are you able to arrange for your own transportation? * Required

Are you able to do your own shopping? * Required

Are you able to use a telephone or cell phone? * Required

Are you able to manage your own finances? * Required

Please identify any funding sources which will be used to pay for your housing expenses. This could be a job, SSI, SSDI or any other income source. * Required

What is your monthly income after taxes ("take home pay")? * Required

Have you ever been convicted of a felony? * Required

Are you currently pending any criminal legal action? * Required

If yes to either, please provide a list of charges below, including the nature of the incidents and legal outcomes:

Are you currently listed in any Registered Sex Offender databases which might affect your residence options? * Required

If yes, please briefly describe any residential restrictions that you are required to follow:

Do you have any medical conditions that may prohibit your ability to live in an independent shared living home * Required

If yes please describe the nature of the applicable disability or condition below:

I affirm that all information provided in this document is true and correct as of the date on which this document was completed. (PLEASE PRINT YOUR FULL NAME)