Thank you for your interest in Conquer Mental Health. Our West Palm Beach recovery home provides a safe, structured, and supportive living environment for men committed to sobriety, personal growth, and independent living.

This application helps us understand your current needs, recovery goals, preferred move-in date, and readiness for structured recovery housing. Please answer each question honestly and completely. Submission of this application does not guarantee admission or immediate placement. Information provided will be reviewed confidentially and used to evaluate eligibility, availability, and appropriate next steps.

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 certify that the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that submitting this application does not guarantee admission or immediate placement. I authorize Conquer Mental Health to contact me regarding my application, eligibility, availability, and next steps.

Agreed by: *

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