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APPLICATION FOR RESIDENCY
Are you currently at a treatment facility?
Yes
No
Have you stayed in a recovery house in the past?
Yes
No
Do you have current or pending leagal charges?
Yes
No
Are you on probation or parole?
Yes
No
Do you have an active warrant?
Yes
No
Are you a sex offender?
Yes
No
Have you been convicted of a violent crime?
Yes
No
Are you employed?
Yes
No
Do you have the funds available for rent?
Yes
No
Do you have a spouse or family willing to help pay?
Yes
No
Do you collect SSI or disability?
Yes
No
Will you be applying for a grant?
Yes
No
Have you participated in 12-step recovery before?
Yes
No
Do you have a sponsor?
Yes
No
Are you currently taking any medications?
Yes
No
Do you need a mental health referral?
Yes
No
Current mental health diagnosis(es):
Current mental health medication(s):
Current mental health provider and last date seen/next appointment:
Previous mental health diagnosis(es) and previous mental health medication(s):
Previous psychiatric hospitalization(s) (date, location, and reason):
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