Application for Recovery Housing

  • Application for Recovery Housing

  • Today's Date
     - -
  • Date of Birth of Applicant*
     - -
  • Format: (000) 000-0000.
  • Do you have a valid ID?*
  • Do you have an insurance card?*
  • Date of last substance use?
     - -
  • Do you currently have any legal problems?*
  • Do you currently have a Probation/Parole Officer?*

  • Emergency Contacts

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Are you currently employed?*
  • Do you attend 12-Step or Other Supports?*
  • Do you currently have a sponsor or other support person?*
  • Are you engaged with therapeutic services?*
  • Do you have any children?*
  • Does the child/children reside in your care currently?
  • If not, are you currently in the process of regaining custody?
  • Is Child Protective Services Involved?*
  • Do you have a vehicle?*
  • Rows

  • Services Providers and Acknowledgement

  • *Recovery housing provides all furniture; bed linens; washer and dryer; kitchen items, etc. for use of participants while in the program.   These are to be used for program purposes only. 

    *Weekly Case Management is provided to assist participants with goal planning, which includes daily living skills.

    *Other staff members including the Property Manager, House Manager, Maintenance Staff, etc. may be subject to drop in when needed or if an issue arises.

    *Copeline, which can be reached at 440-285-5665 may be used to reach an on-call therapist.  The house manager can be reached at 440-687-4805 to reach the house regarding any maintenance concerns.

    *A lock box is provided for each resident to keep their medications and personal items safe.

    *All utilities and trash pickup are provided by the program.

     

  • Acknowledgement

    By signing below I acknowledge that I have completed this application honestly and to the best of my ability.

  • Signature Date
     - -
  • Should be Empty: