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.

9495 Harvard Boulevard

Youngstown, Ohio 44514

1-855-292-9778

info@broadwayrecoveryservices.org

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