Recovery Residence Application

Full Name(Required)

Birth Date(Required)

Phone(Required)

Email(Required)

Gender(Required)

Relationship Status

Current Address(Required)

Do you have parental/family support?(Required)

How did you hear about us?

Do you have chlidren?(Required)

If yes, please list age(s)

Emergency Contact(Required)

Relationship

Phone(Required)

Employment Status

Employer Name

How long?

Hours(Required)

Number of hours per week

Income amount per month

Other source(s) of income

Health

Health Insurance?(Required)

Currently Receiving Mental Health Services?(Required)

Have you ever thought about harming yourself or someone else?(Required)

If the answer is yes please explain:

Currently on any medication?(Required)

If the answer is yes please list medications:

Substance Use & Treatment

Are you in recovery from the use of drugs/alcohol?(Required)

Primary Substance Used(Required)

Years of Active Use(Required)

Date of Last Use(Required)

Do you attend support groups?(Required)

Type of support group:

Currently on MAT?(Required)

Which Medication(s):

Are you currently in a residential treatment program?(Required)

Name and address:

Anticipated Completion Date

Please list goals for 1 month, 6 months and 1 year from today:(Required)

Legal

Are you stipulated to sober living?(Required)

Are you awaiting charges, trial, or sentencing?(Required)

Are you on probation or parole?(Required)

Name & Phone of Parole Officer

Have you ever been convicted of arson or a sex crime or registered as a sex offender?(Required)

If yes, please describe:

Do you own a vehicle?(Required)

If yes, please list Make, Model, and License Plate #

Requested Move-In Date(Required)

Requested Room Type

Authorization for Release of Information(Required)

I hereby authorize Jeremiah's House and its designated agents and representatives to conduct a review of my background. I understand that the scope of this background check may include, but is not limited to the following: verification of social security number; credit reports, current and previous residences; employment history, education background, character references; drug testing, medical records from a treatment facility, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records. I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, to or its agents.

Phone

This field is for validation purposes and should be left unchanged.

Recovery Residence Application