New Resident Application

New Resident Application

Application for Residency

Please fill in the form below
Name

First NameMiddle NameLast Name
Sex
Date of Birth

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

MonthDayYear
Date
Contact Number:

Area CodePhone Number
Contact person (if applicable)
Prior Treatment(s)
Prior Recovery Residence(s)
Most Recent Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
In case of emergency...
Emergency Contact:

First NameLast Name
Relationship
Contact Number

Area CodePhone Number
Marital Status
Do you have any children?
If yes, list names and ages here
Clean date

MonthDayYear
Date
Drugs used
Are you taking any medications, currently?
If yes, please list them here
Any psychiatric or medical history?
describe.
Have you ever been convicted of a sexual or violent crime?
Legal history
Incarcerations, probation, etc.
Do you have a job?
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?
What is your preferred location?

Other
Should be Empty: