DAN'S GROUP HOME APPLICATION
This house is a recovery residence. No drugs or alcohol are allowed on or off the premises. No smoking or vaping is allowed inside the house. No pets. Bedrooms and bathrooms are shared. Furniture, bed, bedding, utilities, TVs, internet, appliances, and kitchenware are included. $650/month + $250 move-in fee. No minimum credit score required to qualify. If you have any questions before applying, please email us at Dan@Dansgrouphome.com.
Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Social Security Number
Email Address
example@example.com
Phone Number
-
Area Code
Phone Number
Driver's License Numer
Do you have an operational vehicle that you want to park at the house?
Yes
No
Are you a veteran?
Yes
No
Marital Status
Single, married, divorced, separated
Spouse / Partner Name
Leave blank if you don't have a spouse or partner
Spouse / Partner Phone Number
Single, married, divorced, separated
Spouse / Partner Email
Single, married, divorced, separated
Current Address
Street Address
Street Address Line 2
City
State
Zip Code
Is your current address your house, your parent's house, a friend's house, hotel, rehab, shelter, or something else? Please explain.*
How long have you lived at your current address?
Name of Employer
Leave blank if unemployed
Total Monthly Income
How much money do you receive every month?
List All Income Sources
Job, child support, SSI, SSDI, etc.
Do you volunteer anywhere?
Leave blank if you don't volunteer
Describe your history with addiction
Explain how long you've been using, any periods of time sober, if you've ever been to rehab, etc.
Sobriety Date
The date after your last time using drugs/alcohol
Drug(s) of Choice
Alcohol, marijuana, cocaine, heroin, etc.
Recovery Program(s)
IOP, AA, SMART Recovery, etc.
What triggers you to use?
Boredom, anxiety, depression, stress, etc.
What are your hobbies?
Emergency Contact #1 Name
First Name
Last Name
What is emergency contact #1's relationship to you?
Parent, spouse, friend, etc.
Emergency Contact #1 Phone Number
Please enter a valid phone number.
Emergency Contact #1 Email Address
example@example.com
Emergency Contact #2 Name
First Name
Last Name
What is emergency contact #2's relationship to you?
Parent, spouse, friend, etc.
Emergency Contact #2 Phone Number
Please enter a valid phone number.
Emergency Contact #2 Email Address
example@example.com
Additional Instructions
Submit
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