Recovery Housing Application

Recovery Housing Application

Recovery Housing Ohio provides certified recovery homes, where residents are supervised. Housing is not a clinical treatment setting.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Are you currently in an inpatient treatment facility?

YesNo
Date of Discharge

MonthDayYear
Date
Name of current Case Manager/ Discharge Facilitator (if applicable)

First NameLast Name
Contact information of current Case Manager/ Discharge Facilitator (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Recovery Housing Acknowledgement Statement
I, First & Last Name*, agree that while in recovery housing I must be willing to participate in my own recovery planning, be willing to provide support to other residents, and be willing to maintain a drug and alcohol-free living environment.

Recovery Housing Acknowledgement Statement