Housing Application
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Sex
*
Male
Female
Other
Refused
Cell Number
Landline Number
E-mail
example@example.com
I consent to be contacted by Rise Up Recovery via SMS, email, or phone using the infomation I provided for the purposes of review my application.
*
Yes
No
Insurance Company Name
Plan Name
Insurance Member ID
Insurance Group ID
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What were the last substances used and when?
*
Do you have any physical health / medical conditions or disabilities?
Yes
No
If yes, please describe
Do you have any mental health issues or diagnosis?
Yes
No
If yes, please describe
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Are you currently in a treatment program?
Yes
No
If no, are you willing to enter a treatment program?
Yes
No
What is the last date you used substances?
*
-
Month
-
Day
Year
Date
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Are you currently involved in any legal proceedings or criminal justice issues?
Yes
No
Do you have any pending sentencing or possible jail time upcoming?
Yes
No
Are you required to register as a sex offender?
Yes
No
Are you required to register with any other authority for any other reason?
Yes
No
Are there any Restraining Orders against you or by you?
Yes
No
When would you like to move in?
-
Month
-
Day
Year
Date
What Recovery Residence are you interested in?
*
Hope House 1 (Women)
Hope House 2 (Women with 1 Child)
Providence House (Men)
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