Recovery Housing Application
Please fill out the following and submit to get in contact with us.
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Carrier
*
Insurance Member ID #
*
Do you have a valid ID and insurance ID card?
*
Yes
No
Please upload a photo of your valid ID
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload a photo of your insurance card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Are you currently using any Rx medications?
*
Yes
No
Select the date of last use
*
-
Month
-
Day
Year
Date
What/ How/ How much are you using?
*
Name of MAT Provider (if applicable)
First Name
Last Name
Contact information for MAT Provider (if applicable)
Please enter a valid phone number.
Frequency and dosage of current MAT Plan
Please describe your prior engagement with recovery treatment:
Name of current Case Manager/ Discharge Facilitator (if applicable)
First Name
Last Name
Contact information of current Case Manager/ Discharge Facilitator (if applicable)
Please enter a valid phone number.
Do you currently have a P.O.?
*
Yes
No
Please explain:
Do you have a primary doctor or specialist that you have seen in the past year?
*
Yes
No
Do you have any legal issues/ charges that will need addressed/ communicated within the next 6 months?
*
Yes
No
Please explain:
Have you been convicted of a sexual offense?
*
Yes
No
Do you know anyone that stays at any of our locations?
*
Yes
No
How did you hear about Recovery Housing Ohio?
*
Please Select
Online
A friend/ family member
At a meeting or event
Other
Are you currently employed (or have a job to go back to)?
*
Yes
No
How will you pay for your stay?
*
Submit
Should be Empty: