ABOUT
- Trusted Partners
GET HELP
- Intake Form
GET INVOLVED
DONATE
- Monthly Donation Plans
CONNECT

INTAKE FORM

Get started by filling out our intake form. Please note, this DOES NOT guarantee a placement, however an intake coordinator will be in contact with you as soon as possible.

If you are in immediate danger, please call 911.

First name*

Last name*

Are you or a representative filling out this application?*

Myself

Representative

If you are a representative, please give us your name, title and agency:*

How did you hear about Ashland Access?

Birthday*

Month

Day

Year

Last four digits of your social security:*

Race/Ethnicity*

Hispanic or Latino

American Indian or Alaska Native

Black/African

Native Hawaiian or other Pacific Islander

White/Caucasian

Other

Best way to get in contact:*

Phone

Text

Email*

Phone*

Current address*

City*

County*

Marital status*

Single

Married

Divorced

Widowed

Separated

Are you receiving government assistance?*

Insurance Information:*

Member ID Number: *

Are you in the Military or a Veteran?*

Yes

Have you been convicted of a felony?*

Yes

If yes, please explain:

Do you consent to a background check?*

Yes

Not at this time

If "Yes" list your previous places of residence, including city, county, and state. If not applicable, but N/A.*

Please update your (or applicant's) state ID or driver's license:*

Please explain your current living situation.*

Do you have children?*

Yes

Do your children live with you?*

Yes

Are you pregnant?*

Do you have a CPS case?*

Yes

If yes, please list your CPS case worker's name and contact information.*

Do you have a current case plan you are working on?*

Yes

Education*

Do you have a physical disability?*

Yes

Do you have a primary care doctor?*

Yes

If yes, please list your physician's name?

Are you on any medications?*

Yes

If yes, please list all medications, what for, and dosage.

Do you have any mental health diagnosis'?*

Yes

If yes, please list the mental health diagnosis.

Are you currently employed?*

Yes

No, but actively applying to jobs

Are you currently employed?*

If yes, where are you currently employed?

Share a church organization you are affiliated with (if applicable).

Do you have any legal issues/cases?

If you have a legal issue, please explain.

If applicable, please share your probation officer's information: name, county, contact info.

REQUIREMENTS OF ASHLAND ACCESS:

No pets
Must be able to pay program fees:
- Month 1: $0
- Month 2: $100
- Month 3: $150
Attend mandatory Access classes and meetings assigned by staff.
Participate in 1:1 mentoring
Abide by facility curfew/check-in at 11:00 pm
No visitors unless approved
Must obtain employment
Must participate and contribute to shelter chores
Obtain employment within 7 days (unless discussed otherwise)
Must agree to:
- Random drug testing
- Random room checks

Ashland Access is a self-driven program. The results you desire will come by the work you contribute and put in.

I understand and I agree with these requirements.*

Yes

Please explain why Ashland Access would be a good fit for you in the next steps of your life/recovery. Be as detailed as possible, there is no right or wrong answer.*

Any other questions or concerns we should be aware of?

A copy of your responses will be emailed to the email provided.

Access Ashland

Ashland Access is a Section 501(c)(3) charitable organization, EIN 45-5478657. All donations are deemed tax-deductible absent any limitations on deductibility applicable to a particular taxpayer. No goods or services were provided in exchange for your contribution.

Email: support@ashlandaccess.com

Phone: 419-903-0099

Address: 228 Maple Street Ashland, OH 44805