• Recovery Housing Bed Request

  • Relationship*
  • What is your available move-in date?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Do you have a photo ID?*
  • Are you able to walk stairs?*
  • Are you currently employed?*
  • Employment Status*

  • Recovery History

  • Sobriety Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Did you undergo medical detox?*
  • Detox Admission Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you currently in residential treatment?*
  • Treatment Admission Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are we able to speak to your current case manager or counselor?*
  • Format: (000) 000-0000.
  • Did you previously complete in-patient treatment?*
  • PREVIOUS Treatment Admission Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you currently have out-patient services?*
  • Which out-patient services are you involved in?*

  • Additional recovery services (Peer Support & recovery planning) and a Drug/Alcohol Mental Health Assessment are required for residency.  A list of in-county agencies that provide peer support and other out-patient services will be provided to you during your Hope Recovery Housing phone interview. 

    We are glad to assist you in the process of obtaining these out-patient services at your request, which may be able to start prior to living at Hope Recovery Community - Recovery Housing.

  • Consent for Out-Patient Services*
  • Have you ever or do you currently live in recovery housing/sober living?*
  • Previous Recovery Housing (add all)*
  • Do you take medications?*
  • Medication List*
  • Are you on any MAT substances?*

  • Criminal Justice Involement

  • Please note, failure to disclose full criminal history or pending warrants will result in termination from the recovery housing program. 

  • Are you a registered sex offender?*
  • Do you have any outstanding warrants?*
  • Do you have any felony convictions?*
  • Are you on probation?*
  • Do you have any pending jail time or upcoming sentencing?*
  • Can you pass a drug/alcohol test?*

  • AUTHORIZATION FOR BACKGROUND CHECK
    By signing below, I authorize Hope Recovery Community to conduct a background check at their discretion for any reason that they deem said background check necessary or helpful to their conducting business.

     

    By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.

     

    Once your form is submitted we will call you to conduct a phone interview.

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