Thank you for your interest in the Recovery Housing Initiative. Our homes are designed to provide a safe, structured, and supportive living environment for individuals who are actively working toward long-term recovery. This application helps us understand your current needs, recovery goals, and readiness for sober living so we can determine whether our program is a good fit. Please answer each question honestly and completely. All information is kept confidential and is used only for the purpose of screening and placement.

Applicant Information

First Name *

Last Name *

Date Of Birth *

Gender *

Primary contact number *

Please enter a valid phone number so we can contact you regarding your application.

Have you lived in one of our homes or applied before? *

Yes

Desired Move-In Timeline *

What is your current address?

Please provide your current legal address here. Include the number (apartment # if applicable), street, city state, and zip code. Please note: this may not be the address where you currently live.

Desired Home or Location

Recovery Background

Date of Last Use *

Legal History/Criminal Background

Have you been convicted of any felonies? *

Yes

Have you ever been found guilty of a sexual offense? *

Yes

Have you ever been convicted of arson? *

Yes

Are you currently on probation? *

Yes

Are you currently on parole? *

Yes

Treatment History

Have you ever been in residential treatment?

Yes

If you are being released from a treatment program, please select from this list. If not, please skip ahead to “Financial Information

Were you in another program previously? (Please select the type of program you last attended)

If you are awaiting a release from jail or graduation from a program, please tell us what that expected date is.

Financial Information

Please describe any and all sources of income which you will use to pay rent *

Additional Information

Please tell us anything that would be helpful for us to know when contacting you.

You might want to note what phone number or email address (personal or caseworker) is the best means of contact.

Terms and Conditions

I hereby authorize RHI and its designated agents to conduct a review of my background including income, housing, treatment, criminal history, or any other public records. I authorize any individual, company, or public agency to release any information, verbal or written, pertaining to me, to RHI or its agents.

Agreed by: *

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