Serenity Homes Application

About You

First Name: Resident first name 
Middle Initial: Resident middle name  
Last Name: Resident last name
Date of Application: Date

Desired Move In Date: Resident move in date  
Birthdate: Resident birthdate
Phone: Resident phone  
Email: Resident email  

Street Address: Resident mailing address  
About Your Addiction 

Do you mainly need help with:


If Other:


What is your drug of choice: Resident substance of choice 
Date of last use:Date  
Substance used:Text field 

Are you currently enrolled in a treatment facility?


If yes, please complete the following:
Treatment Center: Treatment center 1 name

Started: Treatment center 1 started 

Date of Expected Completion: Treatment center 1 ended

Notes: Treatment center 1 notes

Counselor's Name: Contact 1 name  

Counselor's Phone: Contact 1 phone
Counselor's Email: Contact 1 email

Relationship: Contact 1 type
Are you considering, or have you been approved for, 
any outpatient/aftercare treatment?

If yes, where: Resident IOP

About Your Health

List any physical limitations:

List any current medical concerns:


List all prescriptions you currently take:


Medication: Medication 1 name 

Reason: Medication 1 notes

Medication 2: Medication 2 name  

Reason: Medication 2 notes

Medication 3: Medication 3 name 

Reason: Medication 3 notes

Medication 4: Medication 4 name 

Reason: Medication 4 notes

Is there anything else you’d like us to know about you?