1. Shoreline Recovery Application

Shoreline Recovery Application



First Name: Client first name

Middle Name: Client middle name

Last Name: Client last name

Driver’s License (state & number): Text field

Email: Client email

Mobile Number: Client phone

Date of Birth: Client birthdate

Age: Text field

Marital status: Client marital status



If yes, how many and what are their ages? Text field

Gender: Client gender

Treatment center 1 started

Veteran: Client veteran status


Treatment Experience


Are you currently in treatment?

If yes, where? TreatmentCenterHistory

Type of program:Treatment center 1 type

Clinician Name: Treatment center 1 notes

Clinician email address: Treatment center 1 address

Clinician telephone number: Treatment center 1 name


Admission date: Treatment center 1 started

Expected discharge date:Treatment center 1 ended





Sobriety/Clean Date: Recovery history 1 sobriety date

List Alcohol & Drugs of Abuse: Client substances of choice

If admitted, what is your requested move-in date to a Shoreline Recovery home: Date

Please tell us about your recovery history (including past successes and obstacles to maintaining sobriety):

Text field


Sober Living Experience


Have you ever lived in a sober house before?: 


Name of Sober House: SoberLivingHistory



Emergency Contact Information:


Contact #1

Name: Contact 1 name

Phone: Contact 1 phone

Contact 1 type

Email Address: Contact 1 email


Contact #2

Name: Contact 2 name

Phone: Contact 2 phone

Contact 2 type

Email Address: Contact 2 email



List of Current Medications: 


List Psychiatric Medications First

Medication #1 Medication 1 name

Medication #2 Medication 2 name

Medication #3 Medication 3 name

Medication #4 Medication 4 name

Medication #5 Medication 5 name

Medication #6 Medication 6 name

Other Medications: Medication 7 name




If so, what are you allergic to? Client allergies




Employment & Education

Are you employed? 


If yes, who is your employer? Text field

If not, what job plans do you have? Text field

What is your monthly income right now? Text field

Are you in School: 


Highest level of education completed: Dropdown




Do you currently have any pending legal cases?


If Yes, what are you charged with? Text field


Are you currently on probation or parole? 


If Yes, what are you convicted of? Text field


Have you ever been convicted of a felony? 


If yes, what were you convicted of, and in what year did the conviction occur? Text field


Are you currently on the sex offender registry? 




Medical & Psychiatric


Do you have a medical doctor? 


If yes, Text field

Name: Text field

Telephone Number:Text field


Current medical conditions? 

Text field


Do you have a mental health medication prescriber? 


If yes, Text field

Name:Text field

Telephone Number:Text field

 Initials Text field

Do you have a mental health counselor? Checkboxes

If yes, Text field

Name:Text field

Telephone Number: Text field


Psychiatric History:

Have you been diagnosed with or treated for:

Bipolar disorder 




Post-traumatic stress








Psychosis NOS


Obsessive-Compulsive Disorder (OCD)


Alcohol abuse




Substance abuse


Suicide attempt


Interpersonal Violence


Eating Disorder




In order to move into a Shoreline recovery residence you must be vaccinated and boosted or willing to get vaccinated within one day of moving in.

Have you been vaccinated against COVID? Checkboxes

If yes, what are the dates of your vaccinations Date  Date What are the dates of Boosters received? Date  Date

If you haven't received the booster, you will be required to do so to live at Shoreline.

Statement of Perjury

It is important that the information you give us is true and that you understand what happens if you are not giving truthful information on this form. You may be punished by fine or imprisonment or both (18 U.S.C. 1001). To indicate you have read and understand the above, please certify below:

I, Text field, hereby certify that the answers I provided above are truthful. 

Text field (Signature) Date (Today’s date)



Medical Insurance


Insurance Provider: Client insurance provider

Group ID: Client insurance group ID

Policy Number: Client insurance policy #

Primary on Insurance: Client insurance other


Residential Fees


Who will be responsible for paying your residential fees and living expenses if you are accepted into Shoreline Recovery?

Name: Contact 3 name   

Relationship: Text field

Telephone: Contact 3 phone

Email Address: Contact 3 email


Full payment is required in advance to confirm your stay at Shoreline. Please Initial Initials Text field

Shoreline Recovery monthly guest fees are either $800 or $1200 per month depending on single or double occupancy.  Contact Karen directly at karen@shorelinerecovery.org or 203.605.7543 if you are unsure what your specific fee amount is.

We offer several ways to make payment:

Zelle - karen@shorelinerecovery.org
Venmo - @Karen-Ablondi
Cash App - $KarenAblondi
Credit Card - www.shorelinerecovery.org/residential-fees/ By using a credit card through PayPal. You do not need a PayPal account. A 3% service charge is applied.

At Shoreline Recovery, we honor the right of first refusal. In doing so, you will be notified if someone else is looking to move in before you. If you want to guarantee the bed for yourself or a loved one, your financial responsibility will start on that day.  If you decline this right, you will be notified when another bed becomes available. Please Initial  Initials Text field

Shoreline Recovery Cancellation & Refund Policy:

1. Payments made will be refunded in full (less a $50 processing fee) if you cancel 14 days or more prior to your arrival date. Please Initial Initials Text field

2. If you cancel between 13 days and 1 day in advance, a nonrefundable credit (less a $100 processing fee) will be held for one year from the date of issue. Please Initial Initials Text field

3. No credit or refund is available if you cancel on your arrival day or if you do not show up, or if you leave Shoreline after moving in for any reason. Please Initial Initials Initials Text field

4. The monthly guest fee ($800-$1200) is due on the 1st of each month. Please Initial Initials Text field

5. The move-in fee ($400) is not a deposit. It is non-refundable. Please Initial Initials Text field 

6. Guests are responsible for their own food and are required to pay monthly house dues ($20). Please Initial Initials Text field



By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.

Resident Signature: Signature

Date: Date

Please contact Shoreline Recovery at 203.903.5523 after submitting this application to schedule an interview.