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Coordinated Recovery Application
Fill out this form to give us a head-start on your transition to one of our houses.
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* Indicates required question
First and Last Name (Legal name)
*
Your answer
Preferred name (If different than legal name)
Your answer
Pronouns
He/Him
She/Her
They/Them
Other:
Clear selection
Email address
*
Your answer
Phone number
*
Your answer
Are you willing to make a commitment to stay at the house for at least 6 months?
*
Yes
No
Maybe
Do you have health insurance?
Commercial plan
Medical Assistance
PMAP (Medical Assistance Managed by an insurance company like BCBS)
No insurance
Other:
Clear selection
Do you have any felony criminal convictions? If so, please list them. This won't necessarily disqualify you from admittance.
Your answer
Anything else you think we should know?
Your answer
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