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The Divine One Foundation
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Name*
Email
*
Date of Birth*
Phone*
What is your current source of income? SSI/SSDI, VA Benefits, Pension, Employment, Other.
*
Monthly income
*
Sobriety Date
*
Are you working with a caseworker or agency?
*
Yes
No
Are you able to live independently?
*
Yes
No
Do you currently receive mental health services or support? Yes or No (if yes, where)
*
Do you understand that this is a shared occupancy? (per bed/ lease)
*
Yes
No
Expected housing date?
*
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