• Monarch House Interest & Pre-Screening Form

    Please share a few details so we can better understand your current needs. A member of the Monarch House team will contact you within 24 hours to schedule an interview call and determine together whether Monarch House may be a good fit for you. Please complete all the information to the best of your ability. If you have any problems, questions or concerns, they will be addressed during the interview. Monarch House, Inc. does not discriminate for any reason.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Best Contact Method*
  • Is it safe to leave a voicemail or send a text?*

  • Referral and Current Housing

  • Monarch House works with referring partners. Please tell us who connected you with the program.
  • Do you currently feel safe where you are staying?*
  • Is anyone currently threatening you, stalking you, harming you, or trying to locate you?*
  • Are you in immediate danger today?*
  • This form is not monitored as an emergency service. If you are in immediate danger, call 911. If you are experiencing a mental health crisis, call or text 988.

  • Basic Program Fit

  • Are you at least 18 years old?*
  • Are you currently employed?*
  • If not employed, are you willing and able to actively pursue employment, education, benefits, or another approved stability goal?*
  • Are you able to independently manage personal care, medications, meals, laundry, and routine daily tasks?*
  • Are you legally able to live in a shared residence with other adult women?*
  • Do you believe you can safely share a bedroom and common spaces with other adult women?*
  • Do you currently use alcohol, cannabis, illegal drugs, or medications other than as prescribed?*
  • If yes, when was your most recent use?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you willing and able to live in a sober environment without alcohol, cannabis, illegal drugs, or medication misuse?*
  • Are you willing and able to complete intake, regular, and random drug and alcohol screenings under the same policy used for everyone in the home?*
  • Do you currently take any controlled medication prescribed by a healthcare professional?*

  • Readiness and Interest

  • Are you willing to meet with the program team at least twice each week and take consistent steps toward your goals?*
  • Are you willing to participate in household chores, community expectations, workshops, and respectful conflict resolution?*
  • Do you understand that the Monarch House address is confidential and resident visitors are not permitted?*
  • If accepted, are you willing to review and sign the Community Living House Manual and program agreements?*

  • Acknowledgment of Information Accuracy and Program Fee and Services Acknowledgment

  • Program Fee and Services Acknowledgment*
    • A fully furnished shared bedroom and home
    • Electricity, water, gas, trash, and Wi-Fi
    • Groceries and basic food staples
    • Household supplies and cleaning products
    • Basic hygiene products
    • Haircuts
    • Washer, dryer, and laundry detergent
    • Computer and internet access
    • An individualized Flight Plan based on my needs and goals
    • Regular meetings, success coaching, and accountability
    • Mental health and wellness support from qualified professionals
    • Employment and education assistance
    • Financial literacy, budgeting, savings, and credit-repair support
    • Assistance obtaining identification, benefits, health insurance, and other resources
    • Transportation planning and support
    • Life-skills and personal-development workshops
    • Recovery-focused support and regular drug and alcohol screenings
    • Assistance preparing for and securing permanent housing
    • Support from Monarch House staff, the on-site Residential Advocate, and community partners.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: