Transitional Living Request
Personal Information
Do you have an email? (Not your case manager's) *
Yes
No
Birthdate *
Month
Day
Year
Gender Identity *
Male
Female
Other
Race *
Hispanic or Latino
African American
Caucasian
Native American
Asian
Other Race
Are you on disability? *
Yes
No
Next
Housing & Situation
How will you pay? *
Self-pay
I need funding assistance
Reason for assistance request *
I'm in treatment/detox and need assistance for new residence
I'm in a transitional living and need additional funding
I'm coming from jail/prison and need assistance for new residence
Other
Previously been to a transitional living? *
Yes
No
Which Treatment Center? *
Clean Recovery Center
Windmoor
BayCare
ACTS
Other
Which Jail/Prison? *
Pasco County Detention Center
Pinellas County Jail
Florida Women's Reception Center
Other
Discharge Date
Which Transitional Living are you at or going to? *
Back
Next
Health & Documents
Drug of Choice *
Opiates
Meth
Cocaine
Marijuana
Alcohol
Benzos
Fentanyl
Other
History of Overdose? *
Yes
No
Recovery / Sobriety Date
Are You on Medications? *
Yes
No
Are You on Disability?
Yes
No
Work Disability?
Yes
No
Are You Homeless? *
Yes
No
Do You Have Insurance? *
Medicaid
Medicare
Private
None
Other
Tested for HIV/HepC?
Yes
No
Want HIV/HepC Testing?
Yes
No
On Probation?
Yes
No
Sex Offender?
Yes
No
Pending Charges?
Yes
No
Documents on Hand
Do You Have EBT?
Yes
No
Driver's License? *
Yes
No
Identification Card?
Yes
No
Birth Certificate?
Yes
No
Social Security Card? *
Yes
No
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Next
Veteran & Referral
Are You a Veteran? *
Yes
No
Deployed in Combat? *
Yes
No
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Submit
✅ Thank you for your request.
Your transitional living assistance request has been submitted. Someone will contact you shortly.