Community Re-Entry Place Inside/Out
Housing Application
Mailing address: 14221 E.4th Ave Ste.340
Aurora, Co. 80011
Ph# 720-207-5041
Fax # 720-222-0739
GENERAL INFORMATION
1. Date: ___________________________________
2. DOC# & Case Manager: _____________________________________________________________
PED/MRD____________________________________________________________________________
Full Name (First, Middle, Last)
Aliases:
Date of Birth: ________________________
Social Security #:_____________________
ID or Driver’s Licenses State & No:
______
Message Phone:
______
(Circle ID or License and include No.)
Current Address:
Phone:
Marital Status: Married:
Single:
Divorced:
Separated: ________
How Long:
How Long: ________ How long:_________ How long:________
Are you currently involved in a relationship? ______________If so, for how long: ____________________
Race: _______________________________ Employment status:________________________________
U.S. Citizen? Yes
No
Primary Language: _____________________________________
Military Status: Served/Serving U.S. Military: ____Yes ____ No
Reason for Homelessness/Need for Transitional Living: (check all that apply)
Unemployed □ Legal Issues/Prison □ Divorce □ Loss/Death/Disability □ Debt □
Addiction □
Domestic Violence □
Break up of Domestic Partnership □ Refugee □
Emergency Contact:
____________
Address: _____________________________________________________________________________
Phone: ______________________________________________________________________________
Relationship: _________________________________________________________________________
Children:
Name:
1.
2.
3.
4.
5.
Pregnant
Yes
No
Date of Birth:
3. FINANCIAL INFORMATION:
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If yes, due date ____________________
Current Physical Custody With?
A. List all bills you are currently paying including rent, storage, utilities, etc:
__________________
B. List all past bills including student loans. NOTE: This information is for us to help you budget and will not
keep you from being accepted.
__________________
____________
C. Do you think that you generally manage your money well?
D. If you are in debt, what do you see as the main cause?
______
4. CURRENT HOUSING:
A. Describe your current living situation including where you are living (prison, shelter, apartment of your own,
apartment of someone else) and your relationship to other people living with you:
B. How long have you lived in your current situation?
C. How much is your current rent?
D. Why do you want to leave your current living situation?
______________________________
____________
______
______
E. How many times have you moved in the last 2 years and for what reasons?
______
5. MEDICAL:
A. Do you currently have any health problems that require on going treatment (surgery, medication, physical
therapy, etc.)?
B. Have you been hospitalized for medical problems in the past 2 years?
________________________
If so, where and why?
______
C. Have you ever used any illegal drugs?
Which ones?
____________
D. What is or was your drug of choice?
E. When was the last time you used drugs?
______
G. When was the last time you used alcohol?
______
F. Would you say you have experimented, used regularly, or have an addiction to either drugs or alcohol/or
both?
______________________________
G. Do you use drugs:
Do you drink alcohol:
Do you use either of these:
1. Daily
1. Daily
1. With people
2. 1-3 times a week
2. 1-3 times a week
2. Alone
3. Monthly
3. Monthly
3. Both
4. 2-4 times a year
4. 2-4 times a year
5. No longer use
5. No longer use
6. Never used
6. Never used
H. Have you ever received in or outpatient treatment for drug or alcohol addition?
If so: Where? __________________ When? ______________ How long was the program?
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Did you complete the treatment? _______ Have you relapsed since completing treatment
When?
I. Do you smoke cigarettes? _______ Do you have an addiction to nicotine?
____________
______
6. MENTAL HEALTH:
A. Have you ever seen a counselor (one time or ongoing)?
______
If so, for what issues?
______
B. Have you ever been prescribed or are you currently taking medication for mental health or emotional reasons,
What medications are you taking?
__________________
C. List any residential programs that you have been in before including hospitals, drugs and alcohol treatment,
shelters, transitional programs.
Name
Dates
Reason
D. What kinds of support groups have you attended?
______
7. LEGAL ISSUES:
A. List any arrests and the outcomes in the past five years:
______
B. Have you received any DUI’s or DWI’s?
______
C. Have you spent any time in jail/prison? ______________ If so, list each time, length of stay and reason:
______
D. Do you have any outstanding warrants? ________ If so, what for?
______
E. Are you currently on probation or parole? ______ If so, what for?
______
What is your probation or parole officer’s name and phone number?
____________
Do you have any pending court cases? ______ If so, list what court, county/state, court date and cause or
allegations:
__________________
8. EDUCATION:
Highest level of education completed (circle one):
No Schooling
5th-6th Grade
7th-8th Grade
9th Grade
10th Grade
11th Grade
High School diploma
GED
Trade/Vocational School
Some college
College Degree (school and type of degree)__________________________________________________
What are your educational or career goals?__________________________________________________
9. FAMILY HISTORY:
A. Please list parents and all siblings (including step-siblings):
Name
Relationship
City
How Often Seen
1.___________________________________________________________________________________
2.___________________________________________________________________________________
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3.___________________________________________________________________________________
4.___________________________________________________________________________________
5.___________________________________________________________________________________
6.___________________________________________________________________________________
7.___________________________________________________________________________________
BY SIGNING THIS APPLICATION BELOW, I HEREBY AFFIRM THAT I HAVE
ANSWERED ALL QUESTIONS HONESTLY AND TO THE BEST OF MY ABILITY, I
HAVE GIVEN ACCURATE INFORMATION. ALSO, I UNDERSTAND THAT I AM
GRANTING LEGAL PERMISSION TO ALLOW COMMUNITY RE-ENTRY PLACE
INSIDE/OUT TO OBTAIN A CBI BACKGROUND CHECK ON ME AND, IF DEEMED
NECESSARY, I AGREE TO THE RELEASE OF INFORMATION IN ANY
COMMUNICATION WITH ANY OFFICIALS OF THE COLORADO DEPARTMENT OF
CORRECTIONS.
Signature_______________________________________________
Date____________________
Printed Name___________________________________________
Community Re-Entry Place Inside/Out Ministry Program
We are supporting people who need of a “re-entry” back to life that are in the stage of willingness and
readiness to go to any lengths in to transform their lives in order to be reconciled to themselves, their loved
ones and their community. We are focused on the continued process of helping people make the changes
necessary to live a positive healthy lifestyle.
ACRPIO is an affordable faith-based re-entry transitional housing program for ex-offenders and
recovering persons as they transition back into society, and that have the desire to achieve transformation in
their lives.
Community Re-entry Place Inside/Out (CRPIO) is a forward-looking, innovative exceptional FaithBased ministry program designed specifically to help ex-offenders move out of homelessness and
institutionalism. We focus on excellence and uphold the best practices.
1.
Eligibility Requirements:
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Must be 18 years or older
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Must be single
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Must be 6 months’ sober or 4 months’ sober with completed treatment
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Must commit to 3 months to 1 year
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Must have a desire to change negative life patterns
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Must desire self-sufficiency
2.
ACRP Inside/Out Ministry is Centered on the Following Four Elements:
Each participant will receive an assessment to determine their needs and participants that are
entering into CRP Inside/Out, along with the ATR approval for supportive housing services there will
be requirements to participate in the ministry program.
Services provided include housing, spiritual development, pastoral counseling, alcohol, drug and
family counseling, employment coaching, living skills, and urinalysis (UA) and/or breathalyzer (BA)
testing.
A Community Re-Entry Place Inside/Out has a Faith Based Transformational Drug & Alcohol
Program. We are a state licensed and DOC Approved treatment provider. Offering Strategies for SelfImprovement Curriculum, Individual counseling & DUI level I, Level II Education & Therapy. A
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voucher system is available for those who qualify. Supporting housing vouchers will not be
submitted unless requirements are met.
A. Spiritual Development
Each resident will be given many opportunities for personal spiritual development. This will
be offered through morning devotions, Bible enrichment classes/Pastoral faith based support, and
being actively involved in a local place of worship/faith community of their choice. ATR clients are
required to participate in a minimum of 8 sessions up to 1 year in pastoral faith based support within
the CRP Inside/Out.
B. Case Management
A chaplain/counselor will provide each resident with case management that will help each one
address his or her goals, issues, and struggles. Some of these may be spiritual, emotional, physical,
psychological, legal, financial, medical educational or employment-related. The chaplain/counselor
will be their advocate.
C. Drug, Alcohol Counseling
A professional Clinical Chaplain/ counselor will provide each resident with a minimum of 8
sessions up to a 1 year period of Christian-based counseling.
D. Literacy and Education
Each resident will be given the opportunity to further their education and prepare for a life of
successful employment and self-sufficiency.
3.
4.
Participation Schedule – The First 3’s
As outlined in the CRP Inside/Out brochure:
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The First 3 Hours
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The First 3–7 Days
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The First 3 Weeks
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The First 3 Months
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The First 1-3 Years
General Rules:
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Participants must be actively involved in a faith community, recovery group (AA/NA, celebrate
recovery), and all scheduled meetings with a chaplain/counselor, to be able to stay active with the ATR
supportive housing vouchers. A minimum of 8 sessions up to 1 year is required.
The goal of aftercare support is to discover, train, network, and encourage a Community of Care.
The realization of true transformation comes when one has come to a place of willingness to surrender, willing
to do and go to any lengths to recover and heal. Transformation then allows one to begin witnessing the
healing of others manifest, the reciprocity of helping other lives being restored, and transformation instilled.
The individual who comes to CRP Inside/Out has made the decision they want something better for
their lives. It is the process of change and transformation when truth moves from the head to the heart that
the lasting change occurs
WELCOME TO A NEW BEGINNING!
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RULES FOR RESIDENCY
With respect to one another the following rules are to serve as a guideline for all residents of the
property. The rules outlined in this document are NOT meant to be limited to what has been included,
but, in fact, is meant to be used as a guideline by management in determining the needs of the residents,
individually and collectively.
Therefore, management of the property reserves the right to modify the rules, as any such need may occur. Written notification
of any changes will be posted and reviewed with residents prior to implementation.
Adherence is required for any curfews established by parole, when applicable. Whether on parole or not,
all residents are expected to fully cooperate and be respectful and honest with any and/or all parole officers
when they visit. Curfews for CRPIO are as follows 10pm on weekdays and 12 midnight on Friday and Saturday.
Any violations of the rules or any type of criminal activity can be grounds for immediate removal from this housing. Depending
upon the severity, a first violation is considered a warning. A second violation is consideration for possible removal from this housing.
All residents residing on the property must adhere to the following:
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All residents will be required to maintain clean and orderly living areas throughout the house and allow
management access to rooms for inspections, as well as, keep the front and backyards mowed and clean
of debris, including snow.
Beds must be made every morning and kept neat, and rooms clean and organized at all times.
The kitchen and bathrooms must be cleaned after each use.
Conserve energy usage at all times:
o When use of the furnace is needed the thermostat is to be set at all times NOT to exceed 70 degrees.
o When leaving a room turn off lights; when leaving the house turn off all electronic devices – TV’s,
radios, CD/DVD players, etc.
o To conserve water rinse dishes thoroughly after use and load into the dishwasher; run the
dishwasher ONLY for full loads.
o Use the clothes washer/dryer ONLY for full loads. NO guests are allowed to use the laundry
facilities.
o Limit showers to no more than 10 minutes. NO guests are allowed to use the shower facilities.
Use of television, radios and all music devices will be limited with a respect to the “quiet enjoyment” of
other residents, as well as neighbors.
Residents will treat all staff, residents, visitors and property with respect.
Encourage one another instead of criticizing one another when mistakes are made
Live cooperatively with other residents.
Be honest at all times, lying is unacceptable.
No gang colors are to be worn at any time on CRPIO property.
Behavior that is indicative of gang representation is not allowed on CRPIO property at any time.
Eating and drinking will be limited to the kitchen and dining room area.
NO candles are to be used anywhere in the house including each bedroom
A “NO TOLERANCE RULE” applies: Resident will be suspended from the ministry program if, at
any time
o There is contraband in the residents’ rooms, i.e., drugs, alcohol, material of a sexual nature, weapons, stolen
items, etc. If any of these items are found within a resident’s room, this will constitute grounds for prompt
removal from the housing. If necessary, and when applicable, we will ask parole to do room searches.
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o If any resident is found to be selling, using or suspected of drug usage (including marijuana, whether medical or
NOT, and synthetic marijuana) and/or alcohol usage, it will be grounds for prompt removal.
o All residents must submit to random urinalysis tests. If a resident refuses to submit to testing,
the test is considered positive. Resident will be suspended from the ministry program if, at any
time, a urinalysis test is positive for drugs, alcohol, residents parole or probation officer will be
notified.
o NO sexual activity of any kind is permitted on the premises. No men are allowed to hang out;
dating takes place outside of CRPIO housing.
 Your date may pick you up at the door and drop you off at the door only.
o No sexual activity or relationship with one another while residing in this housing and or
participating in the ministry program.
o No man or woman resident of CRP. Inside/Out may enter into ANY of the residency without
management or approval from management.
o NO person of the opposite sex is allowed in any resident’s bedrooms at any time.
Men and women may only gather in a coed manner when directed by management for official and or
professional purposes
Male and female clients of CRP Inside/Out are prohibited from associating with each other outside of
CRP Inside/Out functions and then only in the presence of CRP Inside/Out staff.
NO acts of violence directed toward any resident, management or staff will be tolerated, which includes but is NOT limited
to, fighting, threats, damage to the property, name calling, cursing or racial slurs and can be cause for removal.
A NON-smoking policy applies inside the house and outside in front of the house; smoking is permitted
in the backyard ONLY
NO guests will be present in the house between the hours of 8:00pm and 9:00am. The number of
guests per person is limited to NO more than TWO at a time without prior permission and they are
required to follow all rules as are applied to the residents. Any children of any residents will be allowed
to visit ONLY on a limited basis and with PRIOR approval by the management of Community Reentry Place Inside/Out
There are to be NO space heaters put to use anywhere in the house.
All residents may participate in mentoring, as offered; residents are encouraged to attend a church of
their choice each week.
The Bible study/Living Skills/Employment Coaching presented at the house each week (Wednesday’s).
Attendance of Relapse Prevention groups held once a week, a minimum of 6 months, held Tuesday
Evenings from 5pm to 630pm @ 14221 E. 4th Ave. Ste. 330 Ar. Co. 80011
We encourage Celebrate Recovery, AA, NA attendance.
NO pets allowed living on the property no exceptions.
Residents are required to attend house meetings.
These rules are for your safety, health and general well-being. By signing this form you are agreeing
to be in compliance with ALL rules at ALL times
I ___________________________________________ have read and understand all requirements, rules
and agree to the following requirements for CRP Inside/Out ministry program.
Printed Name_____________________ / Date_____________________
Community Re-entry Place Inside/Out
RATES FOR RESIDENCY
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Security Deposit of $50 - All Rooms
Weekly
$ 113.
Bi-Weekly
$ 226.
Monthly
$ 450. (This includes utilities, water, phone, internet and trash)
WELCOME TO A NEW BEGINNING!
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