TTI ARH Application

Resident Application

Please complete the application below to apply for TTI Allentown Recovery House. TTI Allentown Recovery House is for adult males.

Personal History
Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Social Security Number*
Driver's License Status*
Driver's License #
Please list all forms of I.D you currently possess*
Email Address*
example@example.com
Phone Number*
Do you have a high school diploma?*
How many years of high school do you have completed?*
Please list any other levels of education, trainings, or certifications you possess.

Medical History
Do you have any general health diagnosis?*
If yes, please explain & list any medications
Do you have any mental health diagnosis?*
If yes, please explain & list any medications
Are you on MAT?*
Emergency Contact*

First NameLast Name
Relationship to Individual*
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
May we release your belongings, and/or refund if applicable to your emergency contact within a week's period if you are unavailable? *

Legal History
Are you currently on probation or parole?*
If yes, in which county?
Probation Officer's Name

First NameLast Name
Current Offenses/Pending Charges
We have exclusionary criteria that cosists of the following: Sex crimes, Arson, and Violent crime. Have you ever been convicted of anything that falls under these categories? If so, please expain.*
Are you familiar with the Allentown area?
Please list any treatment programs, community based programs, or outpatient programs you have attended
Please list any drugs used (including alcohol). Identify your drug/drugs of choice.*

Resident Application