Accredited Recovery Housing

Housing Application

Accredited Recovery Housing, Inc provides a safe, secure drug& alcohol free home like environment that is monitored by staff.
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number
Address-Last Known

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@bvu.edu
Do You have a Valid ID?*
Emergency Contact *

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Relationship
Anticipated Date of Move In*

MonthDayYear
Date You Want to Move In

Do You recieve Disabilty/ Social Security Income?*

YesNo
Are you Currently Employed?*

YesNo
*Please note that if you are already employed You will still be expected to abide by ARH policys. At ARH we work closely with outside orgazations to help everyone reach their employement goals. We do understand recovery MUST come first in order to meet and maintain those goals.
Company Employer
Supervisor Name
Employer Phone Number
Please enter a valid phone number.
I understand & agree that it is my responsibility to notify Accredited Recovery Housing if and when my employment status changes. I agree to provide a valid phone number and name of a supervisor at that time.*

YesNo

Primary Care Physician
Primary Care Physician Phone Number
Please enter a valid phone number.
Do You have any Physical Health, Medical Issues/Diagnosis, or Allergies?
Do You have any Mobility Issues/Concerns?
Do you have a current Mental Health Diagnosis?

YesNo
If Yes, list Mental Health Diagnosis
List ALL prescribed Medications:
Are You currently prescribed a MAT Medication?*

YesNo
List MAT Provider:
Do you have current Substance Use Disorder Treatment Provider?*

YesNo
Substance Use Disorder Treatment Provider Contact Info:
I understand and agree that I will be required to complete a release of information for Accredited Recovery Housing and my treatment facility/ team to be able to communicate freely in order to maintain my housing agreement.*

YesNo

Have you ever been convicted of a Felonious, Arson, Violent, or Sexual offense?

YesNo
Legal History
Are you Currently Involved with Any Court?

WHAT TO BRING:

o   Clothing: Each resident may have: 7 shirts, 7 pairs of pants, 7 pairs of pajamas, 3 pairs of shoes, 2 jackets/hoodies, 2 dress outfits, undergarments, and socks

*Clothing is expected to be free from drug/alcohol references.

o   Toiletries (No Aerosals or products containing Alcohol)

o   Reading items, coloring or drawing materials.

o   Cell phones are permitted.

Do NOT bring additional items, as they will NOT be permitted in housing.

*Accredited Recovery Housing is not responsible for items brought into housing.

All Residents will be provided with a laundry bag containing the following items: 1 twin sheet set (including a fitted sheet, flat sheet & pillowcase) 2 bath towels, 2 wash cloths, 1 blanket and 1 pillow. Once the initial items are provided it is the resident’s responsibility to take care and replace these items on their own if necessary.
I have reviewed and agree to the above What to Bring item list. Any Additional Items brought to ARH housing will not be accepted. ARH is not responsible for any personal items brought into housing.*

YesNo
I understand and give my permission for staff to search my belongings prior to entering housing and at any given time thereafter.*

YesNo
I understand and agree that to be a resident with Accredited Recovery Housing I MUST maintain a legal, drug/alcohol-free lifestyle and be enrolled with a Substance Use Disorder Treatment Provider.*

YesNo
I understand that beginning July 1, 2024 I will be required to pay a weekly $75 housing fee, which is due every Monday.*

YesNo
Please contact Accredited Recovery Housing at 937-914-1589 or Housing@arhinc.org if you have any questions.
Should be Empty:

	Yes	Frequency	Last Use
Alcohol
Cannabis (marijuana, pot, grass, hash, etc.)
Cocaine (coke, crack, etc.)
Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)
Methamphetamine (speed, crystal meth, ice, etc.)
Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)
Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)
Street opioids (heroin, opium, etc.)
Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)
Other (specify below)

Housing Application