2025 Designed Future Housing Application
THIS QUESTIONNAIRE MUST BE COMPLETED IN ORDER TO BE CONSIDERED FOR HOUSING. Be detailed, factual and raw with your responses. Don’t add a lot of details. Just list the facts. Your answers will remain confidential.
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1. First and Last Name: *
1a. What name would you like to be called?
2. Email Address: *
3. Phone Number: *
4.  Present Address (Street, City, State, Zip): *
Date of Birth: *
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Currently in Treatment or Facility? *
Do you have an alcohol problem? *
Date of last drink? *
MM
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DD
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YYYY
Do you have a drug use problem? *
Date of last use? *
MM
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DD
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YYYY
Do you want to stop using/drinking? *
How many recovery meetings do you attend per week? *
List all the drugs you have misused: *
Are you employed full time? *
If yes, employment monthly income:
Are you receiving other income? *
If so, other income:
Marital Status *
Doctor Name: *
Doctor Phone: *
Mental Health Professional Name: *
Mental Health Professional Number:
 *
Name of last treatment center/detox: *
Number of times in treatment:
List all of the medications you are currently prescribed:
Can you move in immediately? *
If not, why?
Have you lived in a Designed Future house before? *
If lived in a Designed Future house before, house name:
Also if lived in a Designed Future house before, what was the reason for departure?
Clear selection
If lived in a Designed Future house before, did you leave owing money?
Clear selection
If yes to owing money, how much did you owe?
Emergency Contact #1 (Name, Relationship, Contact Number): *
Rent at Designed Future ranges between $625-$725/month, depending on which room you choose. Your first month's rent is due the day you move in. Do you have the ability to pay rent upon arrival? *
Emergency Contact #2 (Name, Relationship, Contact Number): *
This information is honest and accurate. Initial and Today's Date: *
Use this space to tell us relevant information related to your active addiction and recovery, including why you want to live here.
I realize the Designed Future house to which I am applying for membership has been established in compliance with the conditions of s2036 of the Federal Anti-Drug Abuse Act of 1988, P.L. 100-690, as amended, which requires house members to (A) prohibit all members from using alcohol or illegal drugs, (B) expel any member who violates such prohibition, (C) equally share household expenses, and (D) utilize democratic decision making within the group including inclusion in and expulsion from the group. In accepting these terms, the applicant understands that s2036 conditions are different from the normal due process afforded by some local landlord-tenant laws. 
I have read all of the material on this application form, including the limitations set forth above. I have answered each question honestly and I have a desire to achieve comfortable recovery from substance use disorder.
That's it! You're finished! Simply click the "SUBMIT" button, and we'll be in touch!
All potential residents must have at least 1-week of rent prior to moving in. 
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