New Guest Application Form
We are accepting applications for women to move in immediately in Grafton, MA. We are accepting applications for move in on/around 10/15/24 for men in Worcester, MA. If you have any questions, please email dawn@projecthealinghouse.com
Full Name
*
First Name
Last Name
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your date of birth?
-
Month
-
Day
Year
Date
Phone Number
*
E-mail
example@example.com
What is your current living situation?
Are you currently in treatment?
No
Drug Use
Alcohol
Mental Health
Where are you currently receiving treatment?
Have you previously been in detox, sober living, halfway house, etc?
Yes
No
What is your drug of choice?
What medications are you currently taking?
Are you employed?
If yes, where are you working? What are your hours? What is your pay?
If not, what is your plan to secure a job?
Do you receive SSI, SSDI, food stamps, Section 8, or any other form of assistance?
What are your short term recovery goals?
What are your long term recovery goals?
When are you interested in moving in?
If you are accepted, are you financially prepared to move in?
If you are accepted, are you prepared to live by the rules and expectations of the house and community, and follow all parts of your recovery plan?
Your electronic signature
Submit
Should be Empty: