Residency Application

Core Requirements

MEN'S RECOVERY HOUSING

5 meetings a week, then 3 once employed

Church on Sunday

Weekly minimum of 20 hours volunteer time

Bible study every Thursday evening

10:30PM Curfew Mon-Sun

Morning devotionals at 8:00AM Mon-Fri

Those with arson and/or sex offenses need not apply.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Case Manager's Email (if in Treatment)
example@example.com
Current address / place of occupancy

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which location are you applying for?*

Montgomery CountyWarren County
Are you involved with the Dream Center?*

YesNo
Where are you applying from?*

TreatmentSober LivingHomeIncarcerationHomeless
If you've already completed treatment, do you have a certificate of completion?
If Treatment, please name facility.
If you're currently under a facility's care, please state how many days you've been there.
What are your drug(s) of choice?*

AlcoholFentanyl and/or HeroinOpiatesMethCrack and/or CocaineOther
Sober Date*

MonthDayYear
Tell us a bit about yourself.*
Desired date of arrival if accepted.

MonthDayYear
Should be Empty: