Date of Birth

Contact Number

Email

What is the best way to contact you and when is the best time to contact you?

Address

What is your current housing status?

Desired move in date?

Please provide a detailed summary of your current location/living situation.

Please describe why you are seeking recovery residence.

Please provide a summary of your substance use history, including substances used, for how long and the last time you have used.

Please provide where you feel you are in your recovery process.

Please explain substance use in the last month. (Substances used, quantity, frequency and reason for use)

Are you willing to attend AA/NA, Restoration Recovery Meetings, Counseling, Church, Etc. 5X/Weekly

What do you do to stay sober? Please provide a thorough summary.

Monthly Income ($)

Type of income (Employment/Wage, SSI/SSDI, Unemployment/other)

A requirement of our program is to participate in at least 20 Hours/week of structured time. How do you plan to achieve this requirement?

Why do you want to enter the Restoration Recovery House?

What prescription medications are you currently taking? Do you have a current doctor prescribing them? Please list all medications, doses, and reason they are prescribed to you.

Do you currently have a primary doctor? If so, who/when was the last time you saw them?

To move in, you are required to pay a NON-REFUNDABLE first time fee of $500. Please explain how you will pay your initial move-in cost and then continue to pay rent the following months.

You will have two options of paying rent. Please check the one you prefer.

Date to begin rent

Please list two references (First and Last Name) as well as a contact number we can reach them at. Do not include family members or current residents of the Restoration Recovery House.

Do you have any medical conditions? If so, please list them.

Do you have any disabilities and/or difficulties with activities of daily living? If so, please explain.

Are you in treatment with any other mental health or substance use providers? If so, please list them here and summarize how long you have been engaged in treatment.

Do you have any criminal convictions? If yes, please list the charge(s) and conviction dates. Criminal history will not necessarily disqualify you.

How did you hear about us? Be as detailed as possible. (Name, Location, Etc.)

Please provide any other additional information that would be helpful;ful for us to know while reviewing your application.

Please list two emergency contacts