Tribe Recovery Homes Application
If something doesnt apply to you, please answer with "NA"
Legal First Name: Client first name
Legal Middle Name: Client middle name
Legal Last Name: Client last name
Birthdate: Date Text field
Gender: Client gender
If other, please explain: Text field
Race: Client race
Ethnicity: Client ethnicity
Phone Number: Client phone
Email: Client email
Are you going to have a vehicle at the home? Checkboxes
Valid Drivers License #: Text field
State Issued in: Text field
Insured Through: Text field
License Plate #:Text field
State issued in: Text field
Employment: (If none, please type "None")
Employer: Employer 1 name
Position: Employment 1 position
Insurance: (If none, please type "None")
Insurance provider: Dropdown
Group ID: Text field
Are you on any of the following Medically Assisted Treatments:
Please explain:Text field
PLEASE NOTE we DO NOT accept any narcotic medications including but not limited to: Benzodiazapines, Barbituates, Narcotic pain medications, Amphetamines, etc.
Are you in need of any of the following:
Food Stamps Checkboxes
State Issued ID Checkboxes
Social Security Card Checkboxes
Birth Certificate Checkboxes
Bus Passes Checkboxes
Legal Situation: Dropdown
Please explain: Paragraph
If yes, please provide County or Office of Supervision:
Officer Phone Number:
Officer Email Address:
What is your current financial situation?
Who would be financially resposible for your Program Fees?
Is there anything else you would like to include?
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.
Tribe Recovery Homes performs a CBI Background Check on all potential applicants. This background check is to protect both current program participants and prospective applicants.
By signing you give permission to Tribe Recovery Homes Inc to run a background check.
This background check does not disqualify you from the program eligibility, nor will the results be disclosed to ANY outside entities.
First Name: Client first name
Last Name: Client last name
Approved participant items upon intake:
Clothing Personal Hygiene
4 long-sleeved shirts 1 Shampoo/conditioner 4 short-sleeved shirts 1 Razor 2 dresses or skirts 1 Body Wash 2 pairs of shorts 1 toothbrush/floss 2 pairs of pants 1 Loofah/rag 1 dress outfit 1 Brush 2 dresses 2 Towels 2 pairs of pajamas Makeup 5 pairs socks 7 pairs of underwear 2 bras 2 pairs of shoes 2 sandals 1 pair of dress shoe