Residency Application

Apply for Residency (Strictly Confidential)

* Indicates required field

Name *

First

Last

Alias *

Birthdate *

Phone Number *

Email *

Employer, if applicable *

Drug(s) of Choice (Alcohol, Opiates, Etcetera) *

Do You Have Funds Available for Rent? *

Sobriety Date *

Have You Stayed In a Sober Living Location in the Past? *

How Long Was Your Last Stay in Sober Living? *

Where are you staying now? *

Do you have a significant other (IE: wife or girlfriend)?: *

Number of Past Drug Overdoses *

Last Overdose Date *

Number of Times in Treatment *

Most Recent Inpatient Location? *

Most Recent Psych Hospital Location *

Do You Have Any Allergies? *

If So, Please List *

Are You In Mental Health Treatment? *

Please List Any Medical Health Diagnosis *

Do You Suffer From any Specialized Health Conditions Such as Diabetes or Seizures? If So, Please List *

List of All Current Prescribed, Over the Counter Medications & Supplements *

Current or Pending Legal Charges? *

If Yes, Please Explain: *

Open Warrants? *

In What County or Jurisdiction? *

Sex Offender? *

If Yes, What Level? *

Domestic Violence Charges? *

Are You on Probation/ Parole? *

What County/ Jurisdiction? *

Probation/ Parole Officer Name: *

Officer Phone Number: *

Please Feel Free to Add Additional Comments, Concerns or Questions in the Following Box: *

Submit