What is the applicant's date of birth?
What is the applicant's gender?
When are you seeking recovery housing?
Substance Use Disorder Treatment
When was the last time that you abused a mind/mood altering substance?
Have you ever been diagnosed with a mental health disorder?
If you are not taking any prescribed medication, enter NONE.
What is your current relationship status?
Pre-Trial, Charges and Sentencing
Who referred you to Dismas House of Kansas City for housing support?
If you answered yes, please provide us with an explanation of your limitations: