RESIDENT APPLICATION

 Please note that we are an all-female recovery house and are LGBTQ+ friendly.

DATE OF APPLICATION:  Date

EXPECTED DATE OF ARRIVAL:  Date

REFERRAL SOURCE:  (NAME OF REHAB, PRISON, ETC.) Text field

YOUR NAME:  Client first name Client last name

GENDER AT BIRTH: Text field     GENDER IDENTITY: Text field

PHONE: Client phone

EMAIL: Client email

DATE OF BIRTH: Date

DRUG(S) OF CHOICE:  Text field

SOBER/CLEAN DATE: Date      

PREGNANT?: 
Radio buttons      

CURRENT MEDICATIONS:  Text field

MENTAL & PHYSICAL HEALTH DIAGNOSISES:  Text field

PENDING CRIMINAL CHARGES? 
Radio buttons

            IF YES, CHARGES:  Text field

            COUNTY/STATE:  Text field

PREVIOUS CONVICTIONS?
Radio buttons

            IF YES, CHARGES:  Text field

            COUNTY/STATE:  Text field

CURRENTLY ON PROBATION/PAROLE?   
Radio buttons

            IF YES, AGENCY:  Text field

            AGENT/OFFICER NAME:  Text field

            AGENT/OFFICER CONTACT INFO:  Text field

CURRENT/PREVIOUS EMPLOYER:  Text field

DO YOU HAVE A SPONSOR OR DO YOU AGREE TO FIND A SPONSOR:  
Radio buttons

EMERGENCY CONTACT NAME & PHONE NUMBER:  Text field

ARE YOU WILLING & ABLE TO COMFORTABLY LIVE WITH A DOG? 
Radio buttons

WILL YOU BE ABLE TO AFFORD $140 SECURITY DEPOSIT AND $140 WEEKLY RENT? 
Radio buttons

WILL YOU APPLY FOR A SCHOLARSHIP OR OTHER FUNDING? 
Radio buttons

ANY ADDITIONAL INFORMATION YOU WISH TO PROVIDE FOR CONSIDERATION: 
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