Educate Me to Recovery

Residence Application

Educate Me to Recovery provides structured, supportive recovery housing with 24-hour on-site supervision.

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 application will be sent to Educate Me Foundation Inc. A confirmation will also be sent to the email address you enter above.