Apply for help

Online application

This is the Dream Center application. This preview form does not send anywhere yet.

How to reach us

You can also write flagstaffdreamcenter@gmail.com or drop off a paper application at 2100 E Rte 66, Flagstaff, AZ 86004. The office number is 928.225.5172. Hours are Monday–Thursday, 8:30 AM–4:00 PM.

HIPAA note: Use and disclosure of client information is governed by HIPAA, the Health Insurance Portability and Accountability Act of 1996.

This form is a preview only. Pressing submit will show a thank-you message on this page. Nothing is emailed or saved. The Dream Center is a sober, drug-free transitional housing program. No pets or animals are permitted for residents at any time.

2. Emergency contact

Name Relationship Primary address City State Zip code Country Primary phone Secondary phone

3. Referral / agency source

Name of the person who referred you Relationship Agency Phone Email

5. Applicant current employment

Company name Job title Supervisor name Supervisor phone Company address City / state / zip Company phone Hire date Hourly rate / salary

Full time or part time

Full time Part time

Description of job duties

Pay schedule

Weekly Bi-weekly Bi-monthly Monthly

Do you have a:

Checking account Savings account

6. Co-applicant current employment

Fill this out if someone is applying with you.

Company name Job title Supervisor name Supervisor phone Company address City / state / zip Company phone Hire date Hourly rate / salary

Full time or part time

Full time Part time

Description of job duties

Pay schedule

Weekly Bi-weekly Bi-monthly Monthly

Do you have a:

Checking account Savings account

7. Other sources of income

Income type Income amount Date of month received Income type Income amount Date of month received

8. Vehicles owned

Only one vehicle may be parked on the property. Additional vehicles may be parked on Main St. No parking at the front office building. You must park in the back parking lot.

Vehicle 1

Year Make Model Color Plate number

Vehicle 2

Year Make Model Color Plate number

9. Type of unit applying for

Pricing for units is subject to change at any time per management.

Single living unit — 1 adult with or without children — $850 Studio unit — 2 adults per room, must have an approved roommate at move-in — $500 per person Studio unit — married couple with or without children — $1000

10. Background information

I authorize Flagstaff Dream Center to perform a background check

Yes No

I have not been convicted of a violent crime in the past 5 years

Yes No

Have you ever been convicted of arson?

Yes No

11. Medical history What type of medical insurance do you have?

Doctor’s name Doctor’s phone Dentist’s name Dentist’s phone

Please list any medical conditions, past or present

Have you ever been hospitalized?

Yes No

If so, please provide hospitalization details Please list any prescribed medications you are currently taking Medications are required to be in a personal medication lock box.

Do you drink alcohol?

Yes No

How often do you drink alcohol?

Do you currently use drugs?

Yes No

How often do you use drugs? What types of drugs are you currently taking?

Do you smoke cigarettes?

13. Spiritual information How would you describe yourself spiritually?

Do you regularly attend church service?

Yes No

Name of church City Church denomination How long have you attended this church?

No pets or animals of any kind are permitted for program residents at any time, without exception.

14. Signature and date

Type your name as your signature for this preview.

Applicant signature Date