APPLICATION FOR RESIDENCY

Are you currently at a treatment facility? *

Yes

Please enter treatment center address

Have you stayed in a recovery house in the past? *

Yes

Do you have current or pending legal charges? *

Yes

Are you on probation or parole? *

Yes

Do you have an active warrant? *

Yes

Are you a sex offender? *

Yes

Have you been convicted of a violent crime? *

Yes

Are you employed? *

Yes

Do you have the funds available for rent? *

Yes

Do you have a spouse or family willing to help pay? *

Yes

Do you collect SSI or disability? *

Yes

Will you be applying for a grant? *

Yes

Have you participated in 12-step recovery before? *

Yes

Do you have a sponsor? *

Yes

Are you currently taking any medications? *

Yes

Do you need a mental health referral?

Yes

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):

By applying for residency with Broadway Recovery Services, I understand that if I am prescribed mental health medications for a diagnosed mental health condition, I am required to remain compliant with those medications unless recommended to cease or change medications by my prescriber. If a life threatening or health problem arises due to current medication regimen, you must seek medical attention immediately.

I accept terms & conditions

Your Signature

Thanks for submitting!

Broadway Recovery Services, Inc.

725 Boardman-Canfield Rd Unit C4,
Boardman, OH 44512

1-855-292-9778

info@broadwayrecoveryservices.org

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