Is This a Self Referral? *

Yes

No

Name *

First Name

Last Name

Phone *

(###)

###

####

Name *

First Name

Last Name

Phone *

(###)

###

####

Clean / Sober Date *

MM

DD

YYYY

Which house are you applying for? *

Recovery House, Euclid Ave. Springfield, MA

Preferred Entry Date *

MM

DD

YYYY

Race *

Black/African Decent

White/Caucasian

Latinx

Asian

Two or More Races

Other

Date of Birth *

must be 18 years or older to apply

MM

DD

YYYY

Gender Identity *

Cis-Male

Trans

intersex

non-Binary

Other

Receiving Mental Health Services? *

Yes

No

Current Living Situation *

Living with Family/Friends

Shelter

Residential Treatment

Correctional Institution

Other

Involvement with the Criminal Justice System? *

Yes

No

Recovery Coach? *

Yes

No

Are Special Accommodations Required? *

Yes

No