Application Request Form
The Willing House Logo

Sober Living Application

Thank you for your interest in The Willing House. Please complete the form below and our intake team will reach out to you. Questions? Call (774) 239-7819 · Worcester, MA. Fields marked * are required. All information is kept confidential.

1. About You

First name *
Client first name
Last name *
Client last name
Gender *
Client gender
Date of birth
Client birthdate

2. Contact Information

Phone number *
Client phone
Email
Client email
Current street address *
Client Address
City *
Client City
State *
Client State
Zip code
Client Zip

3. Recovery Background

Where are you transitioning from? *
Dropdown
How long have you been drug and alcohol free? *
Dropdown
Are you on medication for addiction treatment (MAT), such as Methadone or Suboxone? *
Dropdown
If yes, what is your current dosage?
Text field
In the past 30 days, have you attended any self-help or recovery support groups? *
Dropdown
Do you have parental or family support? *
Dropdown
Family support details (Optional)
Text field
Are you currently pregnant? *
Dropdown
If yes, what is your due date?
Date
How did you hear about us? *
Dropdown
Who referred you? (Optional. Name of the person, program, or facility)
Text field

4. Employment

Employment status *
Dropdown

5. Legal

Are you legally mandated or stipulated to live somewhere? *
Dropdown
Are you currently awaiting charges, trial, or sentencing? *
Dropdown
If yes, please describe
Text field
Are you currently on probation or parole? *
Dropdown
If yes, please describe
Text field
Have you ever been charged with or convicted of a violent felony (such as murder or arson), or are you required to register as a sex offender? *
Dropdown
If yes, please describe
Text field

6. Health Insurance

Insurance provider *
Text field
Insurance plan *
Text field

7. Anything Else

Is there anything else you would like us to know?
Text field

Thank you for applying. One of our intake coordinators will contact you to talk further if there is availability at one of our houses.