Application Form

Basic InformationApplication QuestionsWhat stage of your sobriety are you currently in?What type of program or recovery model do you follow (e.g. , 12-Step, SMART Recovery, faith-based, etc.)?Are you currently residing in or receiving treatment at a rehabilitation center? (Yes / No)If yes, please provide the name and location of the facility:Health Insurance?Carrier?How long have you been sober?What substances did you previously use (e.g. , alcohol, drugs)?Please specify the type(s) of substances.What are three personal goals you hope to achieve within the next six months?Are you currently employed? (Yes/No)If yes, please provide where and how long have you been working:If yes, please provide point of contact for employment verification:Please list any medical conditions you have that we should be aware of:Are you on medication? (Yes/No)Have you been convicted of a felony? (Yes/No)Please note that convictions do not play a role in determining if a resident qualifies to live at our property.Please explain any prior criminal chargesAre you on parole? (Yes/No)If yes, please list you parole officer here:Do you have any food allergies? (Yes/No)If yes, please list them here:List your Emergency Contact here:

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Application Form

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