Transitional Living Program Application
RESTART and TLP are short-term transitional housing opportunities for up to thirty (30) days to assist members’
transition into their permanent housing or supported living (CLP, Flex Care, Flex Care Plus, or Flex Care plus
Extended) treatment program. RESTART is operated by Recovery innovations of Arizona (RIAZ) and TLP is operated
by Lifewell.
RESTART’s goal is to provide a short term (up to 30 days) peer supported transitional housing opportunity to individuals
receiving services for serious mental illness with a focus on supporting individuals to develop and implement a Self-Directed
Recovery Plan. Using the 5 recovery pathways (hope, choice, empowerment, spirituality, and recovery environment)
Recovery Coaches will connect with each person to create relationships that will empower them to find meaning and
purpose in their recovery journey. The peer services offered will support and promote recovery in all aspects of the
individual’s life. The level and types of services received will depend on their needs and choice of services, which will be
individualized and directed by each person.





Hours of operation: 8:00 a.m. to 8:00 p.m.
Living skills training
Support provided by Certified Peer Support Specialists with lived experiences
Community support services and resources for integration back into the community
Members will be invited to participate in several recovery opportunities including classes offered by Recovery
Innovations Wellness City and Recovery Education Center and social events offered by RI’s Circle of Friends
TLP-Lifewell- Transitional Living Program
Housing Services include short term residence typically 30 days. Support to find long term housing options and skill building
around applying for and securing long term housing.
Personal Support Services are home & site- based skill building services designed to enhance independent living skills to attain
community tenure. Services include but are not limited to: budgeting, self-management, food preparation, transportation,
assistance with self-administration of medication and wellness.


Hours of Operation: 7:00 a.m. – 11:30 p.m.
Self-Administration of Medications is individually based and services are provided out of our outpatient facility
Sunday-Saturday.
HOW TO ACCESS RESTART/TLP1. The clinical team will notify case management, social worker, probation officer or any involved parties that member
is in need of a transitional bed using the Transitional Living Program Application.
2. The clinical team will email completed application to housing@mercymaricopa.org ***
3. Mercy Maricopa Housing Department will process and refer to the appropriate agency and inform clinical team,
provider, social worker and care management if applicable
4. Clinical team should coordinate with the provider to schedule screening/intake to the program within two (2)
business days of referral.
* This application is good for a 30-day period of time or if circumstances change. A new
application will be required if transitional housing services are still needed.
** IMPORTANT: This is a 30-day transition program. One of the transition plans developed
should be achievable within 30 days.
Page 1 of 3
Transitional Living Program Application
Please complete this form, print/scan and email to: housing@mercymaricopa.org
Member Name:
Gender: Choose an item. DOB: Click here to enter a date. CIS:
AHCCCS T19: ☐ Yes ☐ No SMI Status: ☐ Yes ☐ No COT: ☐ Yes ☐ No
Social Security Number:
Current Living Situation:
PNO:Choose an item. Clinic:Choose an item. ACT: ☐ Yes ☐ No
Use Wheel Chair ? ☐ Yes ☐ No If yes, please explain:
Clinical Director:
Clinical Director Email:
Clinical Coordinator:
Case Manager:
Clinical Coordinator Email:
Case Manager Email:
☐ Yes ☐ No
Does the member require 24 hour supervision/monitoring?
If yes, the referral is NOT appropriate for TLP/RESTART
Does the member require medication prompting?
Is the member on parole or probation? If yes, please include contact information.
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
Does the member have a guardian/advocate? If yes, please include contact information.
☐ Yes ☐ No
Does the member display aggressive behavior?
Does the member have a history of fire setting?
Does the member have a history of suicide attempts?
TRANSITION PLANS- please include dates of applications submitted if applicable Date Apps submitted:
☐ Flex Care Level of Care ☐ 24 hour prior authorization ☐ Community Living Placement ☐ Scattered Site
☐ ACT Housing ☐ Independent living w/ subsidy ☐ Independent living w/o subsidy ☐ Other (please explain)
What is the member’s 1st choice transition plan from TLP/RESTART?
What is the member’s 2nd choice transition plan from TLP/RESTART?
Both Plans are meant to be possible transition plans from the TLP program, not long term treatment goals.
IMPORTANT: This is a 30-day transitional program. One of the transition plans
developed should be achievable within 30-days.
FOR TLP/RESTART USE ONLY
Accepted: Y or N Date:
Declined Y or N: Date:
Page 2 of 3
Admit Date:
Transitional Living Program Application
For the following reasons/codes:
CLINICAL:
☐ Recipient has significant medical needs–C1
ENVIRONMENTAL:
☐ Recipient declined location-E2
☐ Referral packet incomplete/outdated–C2
☐ Inappropriate level of care requested
☐ Higher LOC needed–C3a
Family – declined-E4
☐ No follow-through by clinical team-E5
☐ Recipient ☐ Clinical team ☐ Guardian ☐
☐ Recipient needs 1st floor-E6
☐ Recipient does not want TLP-E7
☐ Does not want roommate-E8
☐ No Show-E9
LEGAL:
☐ Recipient incarcerated, no release date scheduled-L1
Page 3 of 3