Next Chance Recovery Homes

"Take Your Next Chance Here"

 

If you are interested in applying for residency, please complete this general intake form to be added to our waitlist.

First name: Client first name

Last name: Client last name

Preferred nickname: Client nickname

Phone number: Client phone

Email address: Client email

Date of Birth: Client birthdate

Home City/State: Client CityClient State

Next Chance consists of five recovery homes, each with different phases of living. The Pond House (Falmouth), The Farm House (Forestdale), The Ham House (Wareham), Next Level House (Falmouth), and The Graduate House (Falmouth). Which facility are you applying for today? 

Client facility

 

What is your current sobriety date?

(Enter an estimated date for your last relapse if this is not your first attempt in recovery)

RecoveryHistory

What is your substance of choice?

Client substances of choice

What other substances have you abused in the past?

Text field

 

What medications are your currently taking? 

Please list the names of all your medications:

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Do you have any co-occuring conditions? (Please choose all that apply)

Client diagnosis

Please share most recent treatment history including detoxification, residential, PHP, IOP, OP:

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If you are active in a treatment program, please provide your case manger's information so we can reach you:

Case manager name:Text field

Case manager phone number: Text field

Case manager email: Text field

Potential Discharge date: Text field

Do you have any children? If yes, please list their names and ages.

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Do you have any involvement with DCF, Probation, or Parole? (Please specifiy)

Probation 

Please press submit when you have completed this form. Someone will reach out to you shortly to complete a phone interview.

Phone interviews can also be arranged by text to 774-258-8573 or by email to Lana.atamian@gmail.com