House of Serenity Waitlist Form
Complete this form to join our recovery community and start your journey.
Applicant Full Name
*
First Name
Last Name
Preferred Name (if different)
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current City and State
*
Preferred Move-In Timeframe
*
Please Select
As soon as possible
Within 30 days
1-3 months
3+ months
Undecided
How did you hear about House of Serenity?
Please Select
Friend or family
Healthcare provider
Treatment center
Online search
Social media
Other
Briefly describe your current situation
*
Sobriety Date (if applicable)
-
Month
-
Day
Year
Date
Substances you are in recovery from (optional, if you wish to disclose)
Employment/Income Status
*
Please Select
Employed full-time
Employed part-time
Unemployed
Receiving benefits
Student
Other
Do you have regular access to transportation?
*
Yes
No
Sometimes
Preferred Bed/Room Type (if applicable)
Please Select
No preference
Shared room
Private room
Accessible room
Do you have any special needs or require accommodations?
Emergency Contact Name
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Why do you want to join House of Serenity?
*
Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Join Waitlist
Join Waitlist
Should be Empty: