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Peaceful Haven’s Second Chance Homes

We are committed to supporting your successful transition and reintegration into the community through safe, supportive transitional housing. Please provide as much information as you feel comfortable sharing. Your details will be kept confidential and used only to tailor your personalized reintegration and housing plan.

Full Name

Date of Birth

Gender

Male Female Transgender Other

Emergency Contact Name & Phone

Correctional Facility Name

Release Date / Expected Release Date

Length of Incarceration

Conviction State

Conviction County

Nature of Conviction

Parole / Probation Status

Yes No

Are you seeking semi-independent living with a family-like supportive environment?

Yes No

Do you have any special housing requirements or preferences?

Are you currently receiving or eligible for any government assistance or disability benefits?

Yes No

If yes, specify

Do you have any chronic medical conditions? (e.g., diabetes, hypertension, asthma)

Yes No

If yes, please specify

Are you currently taking any medications?

Yes No

If yes, please list medications and dosages

Have you been diagnosed with any mental health conditions?

Yes No

If yes, please specify

Are you currently receiving mental health treatment or counseling?

Yes No

Do you have a history of substance use or addiction?

Yes No

Consent and Privacy

I understand that the information I provide will be used to support my housing and community reintegration plan at Second Chance Homes. I consent to the collection and use of this information according to privacy laws and policies. My personal information will remain confidential and used solely for the purpose of tailoring services to my needs.

Disclaimer

Second Chance Homes provides semi-independent transitional living designed to empower individuals in rebuilding their lives and achieving stability. Our services include furnished rooms, shared living spaces, and supportive weekly check-ins. We do not provide medical or personal care services, nor legal, medical, or clinical advice. We encourage seeking professional advice for specific health or legal concerns. Outcomes cannot be guaranteed, and participation in our program implies acceptance of these terms.

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CONTACT INFO

Phone
951-474-9555
Email
info@PHsecondchancehomes.com

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