First Name: Client first name

Last Name:Client last name

Contact Phone: Client phone

Do you consent to text message correspondence about this application? Checkboxes

Contact Email:Client email

1. Do you have a history of substance use issues?

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 a. If so, what has your recovery journey been like (history of use, treatment, recovery)?

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b. If so, what recovery goals do you want to achieve while living in the recovery residence?

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c. To verify your abstinence from alcohol and illicit drugs, are you willing to submit a urine sample and disclose what medications you are prescribed in order to rule out “false positives”?

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2. Chrysalis Home is a safe haven for the LGBTQ+ (Lesbian, Gay, Transgender, Queer) community. Are you comfortable to share living space, including a bedroom with someone who identifies as gay, lesbian, transgender or queer?

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3. Are you able to provide a copy of a government-issued ID verifying your name and age?

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 4. Are you willing to adhere to and hold others accountable to the “House Rules”?

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5. Are you willing to participate in the required recovery activities?

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6. Are you able to manage basic activities of daily living (ADL) on your own, such as bathing, dressing, continence, eating, and evacuating the home during emergencies?

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7. Are you able to manage instrumental activities of daily living (IADL) on your own, such as self-managing medications, finances, transportation, cooking, shopping, house cleaning, and laundry?

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8. What is your criminal justice involvement history including felony convictions or supervision status?

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9. How will you pay your recovery residence fees and living expenses? Are you employed? Are you willing to work? What financial resources do you have?

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