Erins House Application

Erin's House: 58 Gumpus Road, Dracut, MA 01826

Application for Success Home Membership

**PLEASE NOTE YOU MUST HAVE MINIMUM 90 DAYS RECOVERY**
Name*

First NameMiddle NameLast Name
Email
example@example.com
Date of Birth*

MonthDayYear
Date
Are you currently homeless or without a permanent residence?*

YesNo
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number:
Please enter a valid phone number.
Cell Phone Number:*
Please enter a valid phone number.

Emergency Contacts:
1. (Name)*
(Number)*
(Relationship)*
2. (Name)
(Number)
(Relationship)
Are you currently in a program?

YesNo
Entry the Name, Address and Date of Entry in the Program

What is your substance of choice?*
Sobriety date?*

MonthDayYear
Date
Can anyone provide documentation of your abstinence?*

YesNo
History of substance use disorder treatment in the past 2 years (including detox)*
Have you had any sobriety in the past?*
Do you attend AA, NA, or other self help meetings?*

YesNo
Frequency?*
Do you currently have a home group?*

YesNo
If yes, where?*
Do you currently have a sponsor?*

YesNo

Health Insurance Provider & Policy #*
Are you currently prescribed any medications?*

YesNo

Any medical issues and/or physical limitations?*

YesNo
If yes, please describe*
History of treatment for mental health and/or self-harm in the past 2 years?*

YesNo
Please explain (include dates):*

Are you currently employed?*

YesNo
Enrolled in school?*

YesNo
Engaged in volunteering?*

YesNo
List the locations where you are employed, in school and/or volunteering? *
Do you have any other income?*

YesNo
If yes, from where and amount? (SSI, SSDI, DTA, Unemployment Benefits, etc.)
Total Monthly Income:*

I understand that only completed applications will be reviewed. *

Agree
I understand that I am subject to immediate expulsion from the house if any of the following occur:

1) I use alcohol and/or drugs; other than my prescribed medication(s)

2) I fail to pay my weekly share of house expenses

3) I engage in disruptive/aggressive behavior

4) I participate in any illegal activity on or off the property

I understand that if I am expelled from the house for any of the above reasons there will be no refunds.

I agree to abide by the Erin's House principles and fully subject myself to the rules of this house, including but not limited to, mandatory random drug testing, participation in supportive case management services, and weekly community house meetings.

By signing below, I certify that the information contained in this application is true to the best of my knowledge, that I understand and accept the conditions set forth above for membership in Erin's House, and that I agree to abide by said conditions should I be accepted as a member of this house.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: