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Start Your Recovery Journey Today
Whether you're transitioning from treatment, re-entering the community, or simply ready for a fresh start, we're here to walk beside you every step of the way.
Personal Information
First name
*
Last name
Date of birth
*
Month
Day
Year
Phone
Email
Emergency contact name
*
Emergency contact number
*
Their relationship to you
Recovery Information
Current sobriety date (if applicable)
What substance(s) are you currently seeking treatment or recovery support for?
Current living situation
Treatment history
Medical Information
Do you have any medical conditions, physical limitations, or disabilities that may affect your ability to safely navigate stairs, perform household responsibilities, or participate in daily activities? If yes, please explain
Are you currently taking any prescription medications?
If yes, please list all medications currently prescribed by your healthcare provider.
Do you have any allergies?
If yes, please explain.
What's motivating you to seek recovery housing at this time?
*
Employment and Financial Information
What is your current employment status? (Check all that apply.)
Employed Full-Time
Employed Part-Time
Self-Employed
Unemployed
Seeking Employment
Student
Receiving Disability Benefits
Who will be responsible for paying your recovery residence fees?
Self
Family Member
Community Organization
Government Agency
Sponsor
Other
If another individual or organization will be responsible for payment, please provide:
Name
Organization (if applicable):
Phone
Relationship to applicant:
Legal Information
Are you currently under the supervision of the criminal justice system (e.g., probation, parole, supervised release, drug court, or another court-ordered program)?
*
If yes, please explain:
Who is your parole officer? (if applicable)
Do you have any upcoming court dates or legal obligations?
Are you a registered sex offender?
*
Recovery Readiness and Commitment
Why are you seeking recovery housing at this time?
What does recovery mean to you?
What motivates you to remain substance-free?
What are your goals for your recovery over the next 90 days?
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