Documents – harmonyhavenresidence.com

Have You Been Vaccinated Against COVID-19?

Yes No

Who Is The Best Person To Contact About This Application (Including phone number and/or email address)?

Are You An Alcoholic?

Are You Addicted To Drugs?

Date Of Last Drug Use?

List Of Drugs Used Addictively

When Did You Attend Your First AA or NA meeting?

How Many AA/ NA Meeting Do You Now Attend Each Week?

Are You Employed? If So, Who Is Your Employer?

What Is Your Current Monthly Income?

Place(s) Of Residence During The Past 2 Years

Please Provide Names And Contact Info For The First Reference Who Can Vouch For Your Commitment To Recovery

Have You Ever Been To A Treatment Facility For Alcoholism Or Drug Addiction? If So, List The Treatment Provider

Do You Take Prescription Drugs? If Yes, List The Drugs, Dosage, And The Reason The Drug Has Been Prescribed

Do You Currently Have Any Physical Or Mental Health Issues (Including Depression, ADD, And Anxiety)? If So, Please Describe. *We Reserve The Right To Request A Mental Or Physical Evaluation

Have You Ever Been Charged Or Convicted Of A Felony? Are You On Probation, Parole, Or Have An Upcoming Court Appearance? If So, Please Describe The Circumstances, Charges, And/ Or The Outcome

Name Of Last Education Institution Or School Attended

Do You Have A Drivers License? In What State?

Are You Married? If So, Name Of Spouse

Fathers Name, Address, Phone Number, Email Address

Mothers Name, Address, Phone Number, Email Address

Emergency Contact – Name, Relation, Phone, E-mail

Back-up Emergency Contact – Name, Relation, Phone, E-mail

What Are Your Short Term Goals?

What Are Your Long Term Goals?

Why Do You Think Residing At Mikes Place Could Help You?

What Other Information Is Relevant To This Application?

APPLICANT ACKNOWLEDGEMENT

APPLICANT ACKNOWLEDGEMENT: I understand that if my application is accepted, I will comply with Harmony Haven homes House Rules and Policies statement (Which I have been given the opportunity to read). I understand that these Rules and Policies may change from time to time at the discretion of Harmony Haven homes . I further understand that my residency with Harmony Haven homes is temporary and transitional. I acknowledge that, as a resident at Harmony Haven homes, I am a licensee and not a tenant, and that I have no tenancy rights or interest. As such, I agree that I can be discharged from the premises immediately should it be determined by the Group Manager or a Director (at their sole discretion) to be in the best interest of the house and/ or other house members. Should I refuse to leave the premises immediately upon discharge, I acknowledge that I will be considered to be a trespasser and that the local police department will be called to escort me off the property. I have answered each question honestly and I want to achieve recovery from alcoholism and/ or drug addiction without relapse. *Selection of YES or NO shall serve as the applicants signature for agreement/ understanding of the above statement.