New Resident Application

Application for Residency

Please fill in the form below
Name

First Name Middle Name Last Name
Sex
Date of Birth

Month Day Year
Where will you be coming from?
treatment center, jail, etc.
When is your requested entry date?

- Month - Day Year
Date
Contact Number:

- Area Code Phone Number
Contact person (if applicable)
Prior Treatment(s)
Prior Recovery Residence(s)

Most Recent Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

In case of emergency...
Emergency Contact:

First Name Last Name
Relationship
Contact Number

- Area Code Phone Number
Marital Status
Do you have any children?

Yes No
If yes, list names and ages here
Clean date

- Month - Day Year
Date
Drugs used
Are you taking any medications, currently?

Yes No
If yes, please list them here
Any psychiatric or medical history?
describe.
Have you ever been convicted of a sexual or violent crime?

Yes No
Legal history
Incarcerations, probation, etc.
Do you have a job?

Yes No
What is your plan for employment?
How will you be paying your residential fees?
Funding, self pay, etc. ?
Why do you want to live at The Gratitude House?
Should be Empty:

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