The Landing – Men's Recovery House Application
Please complete this form to apply for the Men's Recovery House (3rd & 4th floors) at The Landing, 131 East Orange Street, Lancaster, PA 17602. Coming home from incarceration? Please use our Reentry Program application instead. Questions? Call or text 717-925-1213.
Program
Desired move-in date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Applicant Information
First Name
*
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Last 4 of Social Security Number
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Street Address
*
City
*
State
*
ZIP Code
*
Where are you currently staying?
*
Home
Treatment facility
Jail/prison
Shelter
Homeless
Other
Emergency Contact
First Name
*
Last Name
*
Relationship
*
Please Select
Parent
Sibling
Spouse
Partner
Friend
Other
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Treatment & Recovery
Are you currently in treatment?
*
Yes
No
Current treatment facility name
Projected treatment completion date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you currently on Medication-Assisted Treatment (MAT)?
*
No
Methadone
Suboxone
Vivitrol
MAT provider name
What recovery program do you attend or plan to attend?
AA
NA
Faith-based program
Other
Sobriety date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Counselor / Case Manager
Do you have a counselor or case manager?
*
Yes
No
Counselor / Case Manager First Name
Counselor / Case Manager Last Name
Agency
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Probation / Parole
Are you currently on probation or parole?
*
Yes
No
Probation/Parole Officer First Name
Probation/Parole Officer Last Name
County
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Do you have any current pending charges?
*
Yes
No
Employment, Education & Background
Work history
*
Are you currently employed?
*
Yes
No
Highest level of education completed
*
Please Select
Some high school
High school diploma/GED
Some college
College degree
Trade certification
Do you have children?
*
Yes
No
Marital status
*
Please Select
Single
Married
Divorced
Separated
Widowed
Military service
*
Yes
No
Referral & Payment
How did you hear about us / who referred you?
Will you need a payment plan for the intake fee, deposit, or rent?
*
Yes
No
Agreement
Certification
*
I certify that the information in this application is true and complete to the best of my knowledge.
Full Name
*
First Name
Middle Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: