• CloverHouse Application for Membership

    To be accepted in a CloverHouse, an applicant must complete this application and be interviewed by the manager of the house.
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Currently in Treatment or Facility?*
  • Do you have an alcohol problem?*
  • Date of last drink:
     - -
  • Do you have a drug use problem?*
  • Date of last use:
     - -
  • Do you want to stop using/drinking?*
  • Are you employed full time?*
  • Are you receiving other income? (retirement, disability, family, welfare)*
  • Marital Status*
  • Can you move-in immediately?*
  • Have you lived in a CloverHouse before?*
  • If yes, what was the reason for your departure?*
  • Should be Empty: