Educate Me to Recovery

Residence Application

Please complete this preliminary application as fully as possible. This is an application—not the resident intake form—and does not guarantee placement.

Your privacy matters. Please do not include a Social Security number, medical records, or other highly sensitive documents.

1 Applicant information

First nameLast nameDate of birthPhone numberEmail addressCurrent city and statePreferred move-in dateBest way to contact you

2 Housing and recovery

Where are you currently staying?Committed to sober living?Currently in a recovery program?What recovery support are you currently receiving? (Do not include private medical details.)Why are you interested in Educate Me to Recovery?

3 Employment and goals

Current employment statusWould you like employment assistance?What are your current goals?What are your interests, hobbies, or skills?

4 Emergency contact

Contact nameRelationshipPhone number

5 Referral information

Referring program or agency nameReferral contact personReferral program phone numberReferral program email addressHow did you hear about us?Anything else you would like us to know?

I certify that the information provided is accurate to the best of my knowledge. I understand this is a preliminary application and that additional screening and intake steps may be required.

Your email app will open with your completed answers. Review the message and press Send.