Restoration Recovery House Application
Full Name
First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
What is the best way to contact you and when is the best time to contact you?
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your current housing status?
Desired Move-In Date
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Month
-
Day
Year
Date
Please provide a detailed summary of your current location/living situation.
Please describe why you are seeking recovery residence.
Please provide a summary of your substance use history, including substances used, for how long and the last time you have used.
Please provide where you feel you are in your recovery process.
Please explain substance use in the last month (substances used, quantity, frequency and reason for use)
Are you willing to attend AA/NA, Restoration Recovery Meetings, Counseling, Church, etc. 5X/Week?
What do you do to stay sober? Please provide a thorough summary.
Are you on - (Employment/Wage SSI/SSDI Unemployment/Other)
A requirement of our program is to participate in at least 20 hours/week of structured time. How do you plan to achieve this requirement?
Why do you want to enter the Restoration Recovery House?
What prescription medications are you currently taking? Do you have a current doctor prescribing them? Please list all medications, doses, and reason they are prescribed to you.
Do you currently have a Primary Doctor? If so, who/when was the last time you saw them?
To move in, you are required to pay a NON-REFUNDABLE first time fee of $500.00. Please explain how you will pay your initial move-in costs and then continue to pay rent the following months.
Date to begin rent
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Month
-
Day
Year
Date
Please list two references (First and Last name) as well as a contact number we can reach them at. Do not include family members or current residents of the Restoration Recovery House.
Do you have any medical conditions? If so, please list them.
Do you have any disabilities and/or difficulties with activities of daily living? If so, please explain.
Are you in treatment with any other mental health or substance use providers? If so, please list them here and summarize how long you have been engaged in treatment.
Do you have any criminal convictions? If yes, please list the charge(s) and convictions dates. Criminal history will not necessarily disqualify you.
How did you hear about us? Be as detailed as possible. (Name, Location, etc.)
Please provide any other additional information that would be helpful for us to know while reviewing your application.
Please provide a picture of the front and back of your Drivers License or any other identification you may have.
Please list two Emergency Contacts.
Signature
Date
-
Month
-
Day
Year
Date
Please upload a picture of the front and back of your Drivers License.
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Please upload a picture of the front and back of your Drivers License.
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