One Step

Application for PorchLight Recovery Sober Living

Congratulations on making a choice to continue your journey at Porchlight Recovery's sober-living community in downtown, historic Lanaster, PA! We encourage you to complete this application early, as space is limited, and we review applications in the order they are received. For assistance, please email or call 833-799-6500. Please allow 24 hours for review of all applications.

General

Tell us about yourself

What is your first name?

What is your middle name? No middle name? Move on to the next question.

What is your last name?

When is your birthdate?

What is your race/ethnicity?

What is your gender?

What is your marital status?

Are you a veteran?

Contact Information

How can we reach you?

What is your email address?

At what phone number can we best reach you at?

Street Address:

City:

State:

Zipcode:

Emergency Contacts

Give us a few people that we can reach out to in case of an emergency.

Contact #1
name:
phone:
email:
type:
EmergencyDon't see the option you're looking for? Click here
notes:
consent:
YesDon't see the option you're looking for? Click here

Medications

List the medications you are currently prescribed.

Medication #1
Name:
Dosage:
Quantity:
Category:
Choose category...Don't see the option you're looking for? Click here
Frequency:
Md:
Notes:
Pill count:
Discontinued at:

Treatment Centers

Tell us about any treatment centers you've previously been admitted into.

Treatment Center History #1
name:
address:
city:
state:
zip:
started:
ended:
notes:
type:
Treatment center typeDon't see the option you're looking for? Click here
reason for discharge:
Treatment center reason for dischargeDon't see the option you're looking for? Click here

Client Referral Source

Who referred you to us?

Occupancy

What date will the you be beginning residency at PorchLight?

What is the estimated length of stay?

Employment

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"

Employment History #1
Employer name:
Employment position:
Employment income:
Employment incomeDon't see the option you're looking for? Click here
Employment started:
Employment ended:
Employment type:
Employment typeDon't see the option you're looking for? Click here
Employment notes:

Thank you for completing the application! Please sign and date the bottom to complete this form: