Mary Isaak Center Emergency Shelter PreapplicationPlease enable JavaScript in your browser to complete this form.The Mary Isaak Center Emergency Shelter (MIC-ES) is a behavior-based, housing-focused shelter program for adult individuals. Qualifications for admission include: - At least 18 years of age - Homeless or at-risk of homelessness (per HUD definition) - Non-violent - Must be able to perform self-care without the assistance of a caregiver - Must be able to live peaceably in a communal setting The Mary Isaak Center Emergency Shelter (MIC-ES) serves individual adults who are experiencing homelessness in our community. COTS staff will not perform full background checks on MIC-ES applicants. COTS staff will perform a standard PC-290 sex offender registry check prior to any individual entering the MIC-ES program. Program Applicants may request a copy of this policy in its entirety at any time. A copy of this policy will be provided to the applicant upon intake. Once your pre-application is submitted, your name will be placed on our waitlist. When your name reaches the top of this list, you will be contacted to come in for a bed. You will have 24 hours to contact us and schedule an intake appointment. Those who do not call within this time frame will be removed from the wait list and will need to reapply. Agreements while staying at the MIC-ES include: - MIC-ES is a housing-focused shelter program. Participants are expected to meet regularly with their Care Manager to work on income development & housing search, and to address individual barriers to housing. - No alcohol, drugs, or related paraphernalia are allowed on COTS property. No purchase or sales of drugs. - No theft or property damage. - No threats, racial slurs or homophobic language; no violence. - Participants are responsible for their own behavior; individuals are asked to respect themselves & the community. COTS is committed to offering low-barrier shelter options to fit a variety of participant needs. Shelter is behavior-based, which means that behavior while in shelter needs to be appropriate and program agreements need to be maintained. Shelter includes case management and client enrichment services with a focus on obtaining permanent housing. This referral form complies with HIPAA Privacy Policies. All information provided will be kept confidential and not used for any purposes other than determining eligibility for placement. Incomplete applications may be deniedName: *FirstMiddleLastSSN: *Phone Number: *Date of Birth (DOB): *Have you stayed at the Mary Isaak Center Emergency Shelter in the past? *YesNoAre you a veteran? *YesNoPrimary Language: *Gender *FemaleMaleNonbinary/OtherWhich pronouns do you prefer? *He/himShe/herThey/themCan you access a top bunk by ladder? *YesNoIf you cannot access a top bunk by ladder, please explain why here:City where you sleep most frequently? *Where do you sleep most frequently? *SheltersCar, van, or RVTransitional housingCouch surfingStreetsOtherIf other, please explain:If vehicle, is it registered? *YesNoIf vehicle, is it insured? *YesNoSource(s) of income: *Monthly $ *How did you hear about COTS? (Check all that apply) *Outreach TeamWord of mouthOnlineCase ManagerPetaluma PD or other law enforcementOtherIn the last 30 days have you been hospitalized, jailed, living in a nursing home, or living in a residential drug or alcohol treatment program? *YesNoSignature * Clear Signature Date of Submission: * veteran? Incomplete Which I consent to receive SMS messages from COTS for the purpose of processing my application and scheduling intakes. Reply STOP to opt out. Reply HELP if you need assistance. Message and data rates may apply. Messaging frequency may vary. *YesNoSubmit