NOTE ABOUT MAINTENANCE MEDS FOR OPIOID ADDICTIONS
Please do not apply if you are using Methadone, Suboxone, or other MAT’s
Monthly Vivitrol injections are the only exception.

IMPORTANT – WE ARE EXCLUSIVELY FOR PEOPLE IN TREATMENT OR ACTIVE PARTICIPATION IN RECOVERY.
We cannot respond to requests from people who are looking for housing for any other purpose.

This form is used to collect information for internal purposes only. The information you provide will remain confidential and privileged. Please answer all questions fully and accurately to the best of your knowledge.

Personal Information

Please provide a brief summary of your history of drugs or alcohol use, legal history, dates of incarceration if applicable, present situation, source of funds, work history, job skills or desires, whatever else gives us a good starting point for an intervew.

History
Mental Health
Medical