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
Do you have a driver's license?
Preferred Method of Contact
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
Are you currently employed?
Date of Sobriety (last use) (if applicable)

MonthDayYear
Date
Have you previously lived in a sober living home?
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
Are you capable of walking at least one mile?
Are you willing to share a room?
How do you plan on paying your rent? Expected amount is 50.00 dollars per week.
Methods of use: snorting, injecting, oral route?
Our program is a minimum of 6 months and a maximum of 2 years. Do you agree to work with our program a minimum of 6 months?
What were your drugs of choice?
If not accepted into our program, what are your plans?
Are you allergic to cats?
Our house is home to an emotional support animal.
Are you willing to comply with the volunteer requirement regardless of your disability and work status?
Should be Empty:

Higher Ground Women's Recovery Residence Application