Are you inquiring for yourself or on behalf of someone else?     Dropdown

 

Prospective Resident Contact Information

First Name:       Client first name

Middle Initial:    Client middle name

Last Name:       Client last name

Telephone #:    Client phone

Age:                 Text field

Email:               Client email

Permanent Street Address:     Client Address

City:                 Client City

State:              Client State

Zip:                  Client Zip

 

Is the Prospective Resident currently admitted to a Facility (Hospital, Detox, or otherwise):     Dropdown

Facility Name (if applicable):     Text field

 

Inquirer's Contact Information (if you are NOT the Prospective Resident)

First Name:       Text field

Middle Initial:    Text field

Last Name:       Text field

Telephone #:    Text field

Relationship to Prospective Resident:     Text field

Email:              Text field

 

Recovery & Medication History

Drug(s) of Choice:      Client substances of choice

Taking prescribed medication(s)?      Dropdown

Complete List of Medications:  Text field

Most Recent Detox Date (if applicable):     Date

Sobriety Date:           Date

 

Making Haven of Hope the Next Step in Your Journey

Desired Move-In Date:    Date

Source of Income:            Dropdown

Have you ever lived in a sober house before?     Dropdown

How did you hear about Haven of Hope?           Dropdown

(If Applicable) Name of the person or organization that referred you:     Text field

 

All new residents must meet Haven of Hope criteria. We will be in touch to follow up on your inquiry but do not hesitate to reach out to us at any time that you may need to (978-258-3982; havenofhopemethuen@havenofhopemethuen.com).