Do you have to register and/or have criminal sexual conduct on your record? *

Yes

No

What was the last date you used ANY substance? *

MM

DD

YYYY

Date Housing is Needed

MM

DD

YYYY

Applicant Information *

First Name

Last Name

Phone

(###)

###

####

Date of Birth *

MM

DD

YYYY

Will this be your first stay at Eazyliven?

Yes

No

Location of Interest

Placement is based off availability

South Minneapolis _ First Ave (40th & 1st)

Richfield _ Portland (74th & Portland)

Emergency Contact Information *

First Name

Last Name

Phone *

(###)

###

####

*

In the event of an emergency, I understand and authorize Eazyliven to contact the individual(s) listed

Do you identify as an addict and/or alcoholic?

Yes

No

Counselor Information

First Name

Last Name

Phone

(###)

###

####

Are you prescribed Suboxone or Methadone?

Suboxone

Methadone

Probation/Parole Information *

Probation

Parole

ISR

None

Agent Information

First Name

Last Name

Phone

(###)

###

####

Are you on civil or mental health commitment? *

Yes

No

Mental/Chemical Health Worker Information

First Name

Last Name

Phone

(###)

###

####

*

I AUTHORIZE EAZYLIVEN TO SPEAK TO INDIVIDUALS LISTED ON THIS APPLICATION IN ORDER TO COORDINATE MY CARE