First Name
Last Name
Email
Phone Number
If the phone number or email address above is somebody else's, but is the only way we can contact you, please provide their name.
Date of Birth (MM/DD/YYYY)
What is the best way to contact you and when is the best time to contact you?
Current or Most Recent Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
If other, please explain.
Desired Move-In Date
Please provide a detailed summary of your current location/living situation.
Please describe why you are seeking a 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 describe 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).
Why do you do to stay sober? Please provide a thorough summary.
Monthly Income ($)
Why do you want to enter Acceptance Recovery House?
What prescription medications are you currently taking? Do you have a current doctor prescribing them?
To move in, you are required to pay a non-refundable $250 fee plus first month's rent of $24 per day the number of days in the month. For example, January would be $744 ($24 x 31 days), but February would be $672 ($24 x 28). Please explain how you will pay your initial move-in costs and then continue to pay rent the following months.
Please list 2 references. Do not include family members or current residents of Acceptance 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?
Please list all medications, doses, and reason they are prescribed to you.
Do you currently have a doctor prescribing the medications listed above? If so, who/when was the last time you saw them?
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 for us to know while reviewing your application.
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