RESIDENT APPLICATION

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

DATE OF APPLICATION:  Text field

EXPECTED DATE OF ARRIVAL: Text field

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

     CASEWORKER/COUNSELOR NAME: Text field

     CASEWORKER/COUNSELOR PHONE: Text field

     CASEWORKER/COUNSELOR EMAIL: 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: Client birthdate

DRUG(S) OF CHOICE:  Text field

RECOVERY START DATE (SOBER/CLEAN DATE): Date      

ARE YOU PREGNANT?: 
Radio buttons      

CURRENT MEDICATIONS:  Text field

MENTAL & PHYSICAL HEALTH DIAGNOSISES:  Text field

PENDING CRIMINAL CHARGES? 
Radio buttons

            IF YES, TYPE OF CHARGES:  Text field

            COUNTY/STATE:  Text field

PREVIOUS CONVICTIONS?
Radio buttons

            IF YES, TYPE OF 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 EMPLOYER:  Text field

IF YOU ARE NOT CURRENTLY WORKING, ARE YOU WILLING AND ABLE TO FIND EMPLOYMENT WITHIN 30 DAYS?
Radio buttons

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

EMERGENCY CONTACT NAME & PHONE NUMBER:  Text field

ARE YOU ABLE TO CLIMB STAIRS?
Radio buttons

ARE YOU ABLE TO LIVE PEACEFULLY WITH OTHER WOMEN?
Radio buttons

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

TELL US ABOUT YOU AND WHY YOU WANT TO COME TO OUR RECOVERY HOUSE:
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