Application

HMH is INTENTIONAL living and does not provide clinical services. HMH is strictly ALCOHOL and DRUG FREE.
The Heart Mind Haven Sanctuary Home is located in Colorado. We do not have residences in other states.
There is no charge to apply. There is a non-refundable, non-negotiable $300.00 intake fee if you are accepted.
Submittal of an application does not guarantee acceptance to our program or housing. Accepted candidates must adhere to our resident’s policy (Resident Handbook). We believe candidates will succeed if their goals align with Heart Mind Haven’s vision and goals for improving wellness within the LGBT+ community.
HMH will run a background check. You will be emailed a link to submit the background check information. If you have any specific situations that you would like to discuss, we advise you discuss with us beforehand. All information is confidential.

All fields must be completed. Leaving any field blank will result in a delay in processing your application.
All information submitted to Heart Mind Haven is confidential.

Date

YYYY

Preferred Name

First Name

Last Name

Legal Name

First Name

Last Name

Preferred pronouns

Date of birth

YYYY

Driver's License Number

Phone

(###)

###

####

Who referred you to us?

Previous address(es) for the last 2 years

Current/previous landlord

If coming from another sober living, please state reason for leaving:

Emergency Contact

Current/previous employer(s). IF NO EMPLOYMENT, PLEASE STATE WHY:

Company, Period of Service (Dates), Position and Supervisor’s Contact Info, Telephone & Email

Income source(s). IF NONE PLEASE STATE REASONS WHY:

Utility Bill, Bank Statement, Payment Stub/Other Verifiable Info

HAVE YOU BEEN HOMELESS AND WHAT ARE THE REASONS YOU FEEL HAVE CONTRIBUTED TO HOMELESSNESS:

Do you have any criminal charges in your background?

If yes, please state below:

Please state the duration of stay you are requesting (months):

HMH wellness housing is offered month to month and is extendable as long as you wish to stay assuming it is good fit for you and HMH.

Automobile

Make, Model, license plate (& state). Note: (ALL cars MUST have valid license plates and be registered in your name to be at the property)

COVID-19 status

Please share your COVID-19 Vaccination Status (All information is confidential)

Are there mental health issues you've been diagnosed with?

Please explain:

Have you been hospitalized due to mental health issues in the last 2 years?

Are you currently working with a therapist?

Are you under psychiatric care and what medications are you on if so:

Are you on an Medically Assisted Treatment, (MAT)? If so, please state what:

Are there substance abuse or alcohol issues you struggle with, now or in the past? Please explain:

By providing this information you agree that it was voluntarily provided and this information will be held in strictest confidence. If you prefer, this information can be communicated verbally during the screening/intake questions.

What are biggest struggles currently and what areas of support are you needing:

Two personal references

Name, phone, email