House of Resiliency Housing Application

The House of Resiliency is the AMAAD Institute's Transitional Residential Living Community located in the King Estates neighborhood of South Los Angeles intended to be especially welcoming to young gay-identified men who need temporary residence in a structured, sober living facility. Email info@amaad.org for more information.

First Name *

Last Name *

Do you have a valid ID? *

Yes

Email Address *

Date of Birth * +

What is your sexual orientation? *

Ethnicity *

Hispanic

Not Hispanic

Would you be comfortable living in a home where Black Gay Men are openly celebrated? *

Yes

Don't Know

Current Address ( if no address put homeless ) *

City

State

Zip Code

Phone Number *

Do You Currently Pay Rent? *

Yes

How much rent do you pay per month? *

Have you ever lived in a transitional living facility before? *

Yes

What transitional living facility have you lived in before?

Are you a student? *

Yes

Grade of Education Last Completed *

Where are you employed? ( if unemployed write "n/a" ) *

Total Monthly Income ( if no income write "0" ) *

In the last 30 days have you used any substances? *

Yes

If yes, what drugs have you used?

Are you currently or planning on attending any outpatient or mental health therapy? *

Yes

Are you currently taking any medications? *

Yes

If yes, what medications are you taking?

Do you currently have a case manager at any agency? *

Yes

Agency Name

Case Manager Name

Case Manager Telephone Number

Name of a Personal or Professional Reference *

Telephone Number of Reference *

Have you ever been convicted of a felony? *

Yes

Describe conviction charges *

Are you currently on probation or parole? *

Yes

Over the past 2 weeks, how often have you been bothered by any of following problems?

Little interest or pleasure in doing things. *

Feeling down, depressed, or hopeless. *

Trouble falling asleep or staying asleep, or sleeping too much. *

Feeling tired or having little energy. *

Poor appetite or overeating. *

Feeling bad about yourself -- or that you are a failure or have let yourself or your family down. *

Trouble concentrating on things, such as reading the newspaper or watching television. *

Moving or speaking so slowly that other people could have noticed. Or the opposite -- being so fidgety or restless that you been moving around a lot more than usual. *

Thoughts that you would be better off dead, or of hurting yourself in some way. *

If you are experiencing any of the above problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? *