Recovery Housing Application
Please fill out the following and submit to get in contact with us.
Date
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Month
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Day
Year
Date
Name
*
First Name
Last Name
Date of Birth
*
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Month
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Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Provider
*
Insurance Member ID #
*
Do you have a valid ID and insurance ID card?
*
Yes
No
Please upload a photo of your valid ID
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload a photo of your insurance card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Are you currently using any Rx medications?
*
Yes
No
Select the date of last use
*
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Month
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Day
Year
Date
What/ How/ How much are you using?
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Name of MAT Provider (if applicable)
First Name
Last Name
Contact information for MAT Provider (if applicable)
Please enter a valid phone number.
Frequency and dosage of current MAT Plan
Please describe your prior engagement with recovery treatment:
Name of current Case Manager/ Discharge Facilitator (if applicable)
First Name
Last Name
Contact information of current Case Manager/ Discharge Facilitator (if applicable)
Please enter a valid phone number.
Do you currently have a Probation Officer?
*
Yes
No
Please explain:
Do you have a primary doctor or specialist that you have seen in the past year?
*
Yes
No
Do you have any legal issues/ charges that will need addressed/ communicated within the next 6 months?
*
Yes
No
Please explain:
Have you been convicted of a sexual offense?
*
Yes
No
Do you know anyone that stays at any of our locations?
*
Yes
No
How did you hear about Recovery Housing Ohio?
*
Please Select
Word of mouth/friend
Discharge Planner
Treatment Provider
Social Media
Other
Are you currently employed (or have a job to go back to)?
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Yes
No
How will you pay for your stay?
*
Why do you feel our recovery housing is a good fit for you and your recovery?
*
ZERO TOLERANCE POLICY
Violation of any of the following will result in immediate self-termination of the lease agreement.
Violence of threats of violence
Unauthorized abscence from facility
Weapons of any kind
Stealing of any kind
Bullying of any kind
Cheeking, sharing, selling, or abuse of medication
Racial or sexual slurs
Destruction to property
Damage to property
Use or possession of drugs, alcohol, or banned substances on or off the property
Behavior not conducive to recovery
Abuse or misuse of over-the-counter medications
Not reporting prescribed medications
Smoking or lighting candles/incense inside the house
Refusal to give a urine screen
Repeated rules violation
Non-adherence to recovery plan
Repeated unauthorized abscence from mandatory treatment (group, peer support, house meetings, etc.)
Fraternizing with others in the house, PHP, IOP, etc.
Violation of the good neighbor policy
Signature (Typed Name)
*
First Name
Last Name
Date
*
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Month
-
Day
Year
Date
Submit
Should be Empty: