Resident Application
Take the 1st step to join our community
Personal Details:
Full Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Are you Male or Female?
*
Male
Female
How did you hear about us?
*
Please Select
Facebook
Instagram
Internet
Magazine
Other
Please Specify
*
Briefly tell us about you
Are You Currently 100% alcohol and drug free?
*
Yes
No
How long have you been sober?
*
Less than 30 days
30-90 days
3-6 months
6-12 months
Over 1 year
Are you willing to submit to regular drug and alcohol testing?
*
Yes
No
Are you currently employed
*
Full-Time
Part-Time
No but actively seeking work
No
If employed, please list your employer name, and your position (If not employed type "NA"
*
Ex: KMart Distribution Center, Forklift Operator
Do you have reliable income to cover weekly program fees?
*
Yes
No
Are you willing to live in a structured, drug and alcohol free environment with rules and accountability?
*
Yes
No
Are you willing to attend required house meetings and/or recovery support meetngs?
*
Yes
No
Do you have any violent crimnal history, arson charges, or sex offender status?
*
Yes
No
Do you have reliable transportation ?
*
Yes
No
Please share briefly why you are seeking sober living and/or transitional housing at this time.
*
Desired Move-In Date
*
-
Month
-
Day
Year
Date
Please give reference of any two people whom you feel could gibe you a reference. This can be your emergency contact:
*
Rows
Full Name
Address
Contact Number
How do you know them?
1
2
By checking this box, I confirm that all answers are truthful to the best of my knowledge
*
I Agree
Submit
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