Wings of Hope Recovery LLC
We welcome individuals who are ready to take the next step and become part of the Wings of Hope community.
Please complete this application as thoroughly and accurately as possible. Incomplete or false information may result in delays or denial of admission.
If you’ve already submitted an application and would like an update, give us a call at (860) 222-2768.
By submitting this application, I confirm that I am committed to maintaining my sobriety and contributing to a healthy, supportive living environment. I believe Wings of Hope can provide the structure and community I need to continue moving forward.
General Information
Applicant (Person interested moving into home)
Applicant's Name Client first nameClient middle nameClient last name
Applicant's Gender Client gender Client pronoun
Applicant's Address Client Address
City, State, ZIP Code Client CityClient StateClient Zip
Applicant's Phone Number Client phone
Applicant's Email Address Client email
Applicant's Date of Birth Date
Today's Date Date
Who is filling out this application? (Skip if filled by applicant)
Radio buttons
Name Text field
Phone Text field
Email Text field
Emergency Contact
Contact
How did you hear about us?
Dropdown
Is This a referral from a treatment center, program, or other organization?
Name of Person referring
Text field
Name of Organization
Text field
Background Information
Criminal History
Is this a court related or TPP referral
Checkboxes
Sex Offender:
Checkboxes
Currently on Parole or Probation?
Dropdown
Have you ever been convicted of a crime? (If yes, please provide details):
Paragraph
Is the Applicant currently incarcerated? (If yes, please provide details):
Correctional Institute
Text field
Estimated Release
Date
Inmate #
Number field
Recovery Background
Date of last use Date
Do you have a sponsor or recovery support system?
Client sponsor
Will you be able to submit a negative urinalysis (drug screen) upon entry into the program?
Dropdown
Substance of choice
Client substances of choice
Treatment History (Optional)
Are you currently in a treatment program?
Dropdown
Release Date
Date
Were you in a program previously?
Dropdown
Release Date
Date
Financial Preparedness & Responsibility
Are you currently employed?
Text field
Current/Most Recent Employer: Text field
Position: Text field Dates of Employment:Date
Additional Info:
Paragraph
Medical Information
Medications
List all medications you are currently taking (prescription and over-the-counter):
Medication
Indicate any history of mental or physical health issues or diagnoses
Client health problems
Checkboxes
Medical Diagnosis/History Notes
Paragraph
Insurance (Used for IOP / Treatment Suggestions)
Text field
Additional Information
Please note anything in regard to contacting you, additional information to be considered for placement or acceptance
Paragraph
Do you have reliable transportation?
Radio buttons
Will you need a parking spot?
Checkboxes
How long do you plan on staying with us?
Client estimated length of stay
Do you need first floor access and room assignment, or would you be comfortable with stairs?
Dropdown
How soon are you looking to join the Wings of Hope Family and become a member?
Date
I understand that my application will be reviewed and that admission into Wings Of Hope Recovery is not guaranteed. I am fully committed to abiding by the rules and guidelines of the sober home, participating actively in the community, and maintaining my sobriety.
I understand that I am required to provide truthful, complete, and accurate information throughout the intake and admissions process. I acknowledge that any false, misleading, or incomplete information I provide—whether spoken or written—may result in denial of admission or immediate dismissal from the program.
Thank you for considering my application. I look forward to the possibility of joining the Wings Of Hope
community and embarking on this transformative journey. Please feel free to contact me at 860-222-2768 or business@wingsofhoperecovery.com if you have any questions or require additional information.
Agreed by:
[Your Signature]
Signature
Date
[Your Printed Name]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.
