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RECOVERY HOUSING APPLICATION

Thank you for taking this step toward stability. This application helps us understand your situation and determine if Recovery Housing is the right fit for you right now. All information is kept confidential. Our team will respond within 3–5 business days.

Section 1 — Applicant Information

Full legal name

Date of birth

Phone number

Email address

Current mailing address

Emergency contact name, relationship, and phone number

Section 2 — Voluntary Demographic Information

This section is voluntary and used only for internal reporting and grant/funder compliance. It does not affect your eligibility or application in any way.

Gender

A
B
C
D
E

Race

Ethnicity

A
B
C

Do you identify as having a disability?

A
B
C

Section 3 — Program Eligibility

What is your current sobriety date, or expected move-in sobriety date?

Are you currently enrolled in or have you completed a treatment program?

Are you willing to participate in random drug testing as a condition of residency?

A
B

Are you currently taking any prescribed medications relevant to your recovery?

Is your housing court-ordered, treatment-ordered, or self-initiated?

Section 4 — Current Situation & Finances

What is your current living situation?

Do you have a current source of income?

How do you intend to fund your housing fees?

Do you have any pending legal issues we should be aware of?

A
B

Do you have any physical or mental health needs that would affect your housing placement or accommodations?

Section 5 — Agreement & Consent

I understand this is substance-free, structured housing and agree to abide by house rules.

I consent to a standard background and safety screening as a condition of consideration.

I understand this application does not guarantee placement and is subject to availability.

Signature and date

Sign here