Recovery Housing Application

Recovery Housing Application
Your most recent mental health and/or addiction assessment/evaluation is required prior to processsing your application for our recovery housing.
Name*

First NameMiddle NameLast Name
Phone*

Area CodePhone Number
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Biological Gender*
Marital Status*
DOB*

MonthDayYear
Date
Social Security*
Home you are applying for:*
Referral Source*
"Other" Referral Source*
Mode of Transportation*

own vehiclefamily/friendwilmington transit

Do you have the following?*

Have you ever been convicted of a felonious, violent, or sexual offense?*

YESNO
Legal History (include dates and charges/convictions)*
Are you involved with any Court?*

YESNO
List courts and dates

Current Mental Health and/or AddictionTreatment Center (name of inpatient, outpatient, residential, etc)*
Previous Mental Health and/or Addiction Treatment Centers (include dates)
Do you have any current mental health and/or addiction diagnoses?*

YESNO
Current Mental Health and/or addiction diagnoses*

What are your goals and expectations?*
Treatment Evaluation (most recent)

Browse Files
(ie, mental health eval, drug/alcohol eval) Cancelof
Should be Empty:

	Check if YES	Frequency	Age of Initial Use	Last Use
Alcohol
Cannabis (marijuana, pot, grass, hash, etc.)
Cocaine (coke, crack, etc.)
Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)
Methamphetamine (speed, crystal meth, ice, etc.)
Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)
Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)
Street opioids (heroin, opium, etc.)
Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)
Other (specify below)