INTEREST FORM
Email
*
Full Name
*
Date of birth
*
Phone
*
How much is your monthly income?
Housing Info
Current Living Situation:
With family
Renting
Homeless
Treatment program
Other
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If Other:
Desired Move-In Date
BASIC SCREENING
Are you graduating from one of our programs?
Yes
No
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If YES, which one?
Graduation date
Are you currently sober?
Yes
No
Working On It
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What is your sobriety/clean date?
Do you have any medical or mental health needs we should be aware of?
*
If yes, please explain:
Professional References:
*
How did you hear about us?
Referral
Online search
Word of mouth
Other
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Anything you’d like us to know about your recovery journey or housing needs?
Agreements
*
I understand I must follow the sober living rules (no drugs/alcohol, random drug screens, no guests, etc).
I understand I will be responsible for bed fee/program payments.
I understand my application does not guarantee placement.
SUBMIT