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

Children: Checkboxes


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

Gender: Client gender

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: RecoveryHistory

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):



Sober Living Experience

Have you ever lived in a sober house before?: 


Name of Sober House: SoberLivingHistory

When did you live there and for how long? Text field



Emergency Contact Information:


Contact #1 Name, Phone, Email



Contact #2 Name, Phone, Email





List of Current Medications: 

List Psychiatric Medications First





If so, what are you allergic to? Client allergies




Employment & Education

Are you employed? 


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

Employer name and income:


Are you in School: 



Highest level of education completed: EducationHistory




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


Telephone Number:Text field


Current medical conditions? Client health problems

Do you have a mental health medication prescriber? Checkboxes


If yes, Text field

Name:Text field

Telephone Number: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:

Client diagnosis

Bipolar disorder 




Post-traumatic stress








Psychosis NOS


Obsessive-Compulsive Disorder (OCD)


Alcohol abuse




Substance abuse


Suicide attempt


Interpersonal Violence


Eating Disorder




Medical Insurance


Insurance Provider: Insurances



Residential Fees


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

Name: Contact   


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 - 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 before 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 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.