Healing Point Eligibility Screening Application

Healing Point House

Initial Eligibility Assessment Application - If your answers to this screening questionnaire deem you eligible, you will automatically be taken to the full application. Please do not close out your web browser.
Today's date *

Month Day Year
Applicant name *

First Name Last Name
Date of birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone number *
Please enter a valid phone number.
Email
example@example.com
How were you referred to Healing Point House? *

I certify that the information I have provided in this application is correct to the best of my knowledge. I confirm that any misrepresentation of facts I have provided would be grounds for removal from the Healing Point House Sober Living Program. I acknowledge that I understand I will not be considered for residency at the Healing Point Sober Living House if I have any history of violent or sexual offenses. I also understand that my spouse/partner/children/other dependents may not reside with me. *

Clear

PLEASE READ FIRST!

You are now eligible to complete the full application. You will automatically be redirected to the full application upon clicking 'Next'.
Should be Empty:

Healing Point House