Applicants Name

 Client first nameClient middle nameClient last name

Preferred Location 

Checkboxes 

Birth Date

Client birthdate

Age 

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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? 

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Clean Date

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What Is Your Plan For Recovery?

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Do You Have Medical Insurance? 

Dropdown

If So, the Medical Insurance Company's Name

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Insurance Card Information

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List Of Any Prescription Medications, If Any

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Any Legal Issues, Past Or Present? 

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

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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?  

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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?) 

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Requested Move-In Date 

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Emergency Contact

Contact

Probation/Parole/ISP Officer Name

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Probation Officer/Parole/ISP Contact

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Drivers or State Issued ID

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Do you have a motor vehicle 

Dropdown

If So, the Make And Model Of the Vehicle

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License Plate Number

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Anything Else You Would Like To Tell Us?

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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 provide you with some insight into the interview process.

During the interview, you’ll have an opportunity to share your situation and explain what led you to seek recovery housing. The house members will also have a chance to ask you questions, and you’ll be encouraged to ask any questions you may have in return. You’ll be informed of all the expectations and requirements for living in the house, as well as the ways residents hold each other accountable.

The purpose of the interview is to determine whether you would be a good fit for the specific house and its community.

 

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