Applicants Name

Client first nameClient middle nameClient last name

Preferred Location 

Checkboxes 

Birth Date

Client birthdate

Age 

Text field

Email Address

Client email

 

 

To become a member of one of our houses, you must be willing to comply with, but not limited to 

To become a member of one of our houses, you must be willing to comply. Check each box to agree.

Checkboxes 

Phone

Client phone

Are You Currently In Treatment?

Dropdown

If So, Where? 

Text field

Clean Date

Date

What Is Your Plan For Recovery?

Paragraph

 

 

 

Do You Have Medical Insurance? 

Dropdown

If So, the Medical Insurance Company's Name

Text field

Insurance Card Information

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List Of Any Prescription Medications, If Any

Text field

 

 

 

Any Legal Issues, Past Or Present? 

Text field

Are you currently on Probation, Parole, or Drug Court, or do you have any charges pending? If So, For What

Text field

Have you ever been accused of or convicted of any violent crimes? If so, what happened? 

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Have you ever been accused of or convicted of a sex crime, or are you on Megan’s Law?

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Will you be attending outpatient services? If so, where? 

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Do you have the finances or funding needed to move in if accepted?  

Text field

Do you understand that upon acceptance, we do not supply bedding (Sheets, Pillows, Blankets, etc.)

Checkboxes

What is the best way to contact you? (Will We Be Contacting You Directly Or A Third Party?) 

Text field

 

Requested Move-In Date 

Date

Emergency Contact

Contact

Probation/Parole/ISP Officer Name

Text field

Probation/Parole/ISP Officer Contact

Text field

Drivers or State Issued ID

Text field

Do you have a motor vehicle 

Dropdown

If So, the Make And Model Of the Vehicle

Text field

License Plate Number

Text field

Anything Else You Would Like To Tell Us?

Paragraph

 

Demographics

The demographic information provided in this application is purely for statistical purposes and will not impact the evaluation of your application.

What Is Your Race/Ethnicity (Check All That Apply):

Checkboxes

Gender:

Checkboxes

Please reach out to Jake for men's & women’s housing ASAP.

By Checking This Box I Acknowledge I Must Reach Out To Jake AFTER SUBMISSION 

Checkboxes

After speaking with Jake, we want to give you some insight into the interviewing process.

At the interview, you'll be given an opportunity to explain your situation and what brought you to seek a recovery house. there will be a time for the house to ask you questions as well as a time for you to ask questions you may have. you will be informed on all the requirements for living there and all the ways house members hold each other accountable.

the interview process is primarily to determine if you will be a successful fit in a specific house.

 

CONTACT:
Jake Lange
Intake Coordinator
732-610-2298
Jake@recoverrevolutionnj.org