Addmission Form

Meadows Retreat

Resident Application
Welcome to Meadows Retreat. If you’re visiting our site, you or someone close to you is likely dealing with a substance use-related illness. Below you will find some questions that help us learn a bit about you so we can determine how we can help.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Have you ever been known by an alternate name?
Birthday*

MonthDayYear
Date

Contact
To receive a response please provide at least 1 form of contact.

Cell PhoneLand lineEmail
Cell Phone
Please enter a valid phone number.
Land Line
Please enter a valid phone number.
Email
example@example.com
I consent to be contacted by Meadows Retreat via SMS, email, or phone using the information I provided for the purposes of reviewing my application.

Agree

Current Living Situation
We understand that everyone has a unique journey.

In order to better understand your transition to our program it is helpful to understand your current living situation.
What best describes your current living situation?

Mental Health
Do you have any mental health issues or diagnosis?*
Do you have a history of self-harm?*
Have you ever experienced any suicidal ideations, attempts, or received in-patient treatment for self-harming behaviors?*
Do you have an Eating Disorder or Body Image Disorder?*
Do you have a need for mental health services?*
Have you ever been a victim of sex trafficking?*
Have you ever been involved in prostitution?*
Do you currently have a purpose in your life?*
Do you currently have goals and hopes for your future?*

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Do you have an attorney?*
Do you consent to a background check?*
Please sign below to consent to a pre housing background check.
I give consent for Meadows Retreat to conduct a background check.

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Are you currently involved in any legal proceedings or criminal justice issues?*
Do have any court ordered treatment requirements?*
Do you have any pending sentencing or possible jail time upcoming?*
Have you ever been charged or convicted of Arson?*
Have you ever been charged or convicted of a Felony?*
Have you ever been charged or convicted of any violent crimes in any jurisdiction?*
Have you ever been charged or convicted of abuse or neglect of any person, including but not limited to disabled person, senior, or child?*
Have you ever been charged or convicted of abuse or neglect of any person, including but not limited to disabled person, senior, or child?*

Admissions
When would you like to move in?*

MonthDayYear
Date
Do you expect to move in on time?*
Do you have a personal relationship with anyone that works for Meadows Retreat?*
Have you previously applied to Meadows Retreat?*
If yes, what date did you previously apply?

MonthDayYear
Date
How long would you hope to stay at Meadows Retreat?*

Client Statement
Were you referred to Meadows Retreat?
What other information should we consider when reviewing your application?
Please describe
What do you want to accomplish while residing at Meadows Retreat?
Please describe

Additional Info
Please enter any other information about yourself or your situation that you feel we need to know
Please describe
By signing below I attest that all the information provided is true and accurate. Providing false or misleading information can result in removal from Meadows Retreat Sober Living home.
Signature*

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Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

Meadows Retreat