Higher Ground Women's Recovery Residence Intake Form

Higher Ground Women's Recovery Residence Application

Please fill out the form to register for the sober living home
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Current Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
YesNo
PhoneEmailText MessageOther
Emergency Contact Name*

First NameLast Name
Emergency Contact Relationship*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Expected Move-in Date

MonthDayYear
Date
YesNo
Date of Sobriety (last use) (if applicable)*

MonthDayYear
Date
YesNo
Do you have any allergies or medical conditions we should be aware of?*
Please briefly describe your reason for seeking residency*
Please list any medications you are currently taking*
YesNo
YesNo
How do you plan on paying your rent? Expected amount is 50.00 dollars per week.
SnortingInjectingOral route
YesNo
What were your drugs of choice?
If not accepted into our program, what are your plans?
YesNo
Our house is home to an emotional support animal.
YesNoWill discuss at interview
Should be Empty:

Higher Ground Women's Recovery Residence Application