M-SARR Membership Application
Type of Membership:
*
Please Select
New Member
How did you hear about M-SARR?
Section I: Member Information
(information on the organization or individual operating a recovery residence)
Applicant or Business Name:
*
Facebook/ Twitter (or other social media) Address:
Principal Business Contact Name:
*
Title:
*
Street address
*
Street address line 2
City
*
State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code
*
Phone number
*
E-mail Address
*
Fax:
Website Address:
Is your organization currently registered to conduct business in the State of Maryland?
*
Yes
No
Pending
Type of Organization:
*
Please Select
Corporation
Non-Profit
Other
Total Number of Recovery Residences owned/operated by organization
*
Number of Single Family Residence(s)10 Beds or less (SFR)
*
Number of Multi-Unit Dwelling/ Apartments (MUA)
*
Facility (FAC)
*
Total Resident Capacity:
Total Resident Capacity SFR:
Total Resident Capacity MUA:
Total Resident Capacity FAC:
Is your organization equipped to provide reasonable accommodations for persons with disabilities?
Yes
No
Section II: Services
Please select the services provided directly by your organization.
Modality/ Speciality
Medical
Mental Health
12-Step
Faith-Based
Co-Occurring Disorder
Other
Treatment Services
Detox
Inpatient
Outpatient
Residential
Individual
Group(s)
Other
Counseling
Individual
Group
Couples/ Marital
Family
Pastoral
Other
DUI Education
Licensed Evaluation
Licensed Treatment
Driving School
Other
Accepted Types of Payment :
Nominal/Sliding Scale/ Negotiable
Free
Scholarship
Insurance Accepted
SSI Accepted
Veterans Benefits
Supplemental Nutrition Assistance Program (SNAP)
Rehabilitation
County Mental Health
Medicare
Medicaid
Other
Section III: Recovery Residence Information
Property #1
Date residence was established:
-
Month
-
Day
Year
Date
Telephone Number
Contact Name
Street address
Street address line 2
City
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code
Property Ownership:
Please Select
Owns Property
Leases from Third Party
Leases from Related Person/ Entity
Other
E-mail
Is this property licensed by the State of Maryland to provide services for:
Mental Health
Substance Use Disorder
Behavioral Health
None of the Above
Other
Is this property licensed by the State of Maryland to provide services for:
Mental Health
Substance Use Disorder
Behavioral Health
None of the Above
Other
List types of reasonable accommodations for persons with disability provided.
Number of Bedrooms:
Age Range:
18-24
25- 44
45-64
65+
Type of Structure:
Single Family Residence- 10 Beds or less
Multi-Unit Dwelling/ Apartments
Facility (Over 10 beds)
Population Served:
Women
Men
Co-Ed
Re-Entry
Medication Assisted Recovery (MAR)
Parents and children
LGBTQI
Youth (under 19 years old)
Senior Citizen (62+)
Laundry on Site:
Yes, Coin Operated
Yes, Included in Resident Fee
No
If leased, do you have written permission from property owner to operate a recovery residence?
Yes
No
Other
Number of Bathrooms:
Basic Weekly Resident Fee
Is Food included?
Yes
No
Additional Fees? Please be specific.
Property #2
Date residence was established:
-
Month
-
Day
Year
Date
Telephone Number
Contact Name
Street address
Street address line 2
City
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code
Property Ownership:
Please Select
Owns Property
Leases from Third Party
Leases from Related Person/ Entity
Other
E-mail
List types of reasonable accommodations for persons with disability provided.
Number of Bedrooms:
Age Range:
18-24
25- 44
45-64
65+
Type of Structure:
Single Family Residence- 10 Beds or less
Multi-Unit Dwelling/ Apartments
Facility (Over 10 beds)
Population Served:
Women
Men
Co-Ed
Re-Entry
Medication Assisted Recovery (MAR)
Parents and children
LGBTQI
Youth (under 19 years old)
Senior Citizen (62+)
Laundry on Site:
Yes, Coin Operated
Yes, Included in Resident Fee
No
If leased, do you have written permission from property owner to operate a recovery residence?
Yes
No
Other
Number of Bathrooms:
Basic Weekly Resident Fee
Is Food included?
Yes
No
Additional Fees? Please be specific.
Property #3
Date residence was established:
-
Month
-
Day
Year
Date
Telephone Number
Contact Name
Street address
Street address line 2
City
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code
Property Ownership:
Please Select
Owns Property
Leases from Third Party
Leases from Related Person/ Entity
Is this property licensed by the State of Maryland to provide services for:
Mental Health
Substance Use Disorder
Behavioral Health
None of the Above
Other
List types of reasonable accommodations for persons with disability provided.
Number of Bedrooms:
Age Range:
18-24
25- 44
45-64
65+
Type of Structure:
Single Family Residence- 10 Beds or less
Multi-Unit Dwelling/ Apartments
Facility (Over 10 beds)
Population Served:
Women
Men
Co-Ed
Re-Entry
Medication Assisted Recovery (MAR)
Parents and children
LGBTQI
Youth (under 19 years old)
Senior Citizen (62+)
Laundry on Site:
Yes, Coin Operated
Yes, Included in Resident Fee
No
If leased, do you have written permission from property owner to operate a recovery residence?
Yes
No
Other
Number of Bathrooms:
Basic Weekly Resident Fee
Is Food included?
Yes
No
Additional Fees? Please be specific.
Type of Structure:
Please Select
Single Family-Detached
Townhouse/ Row House-Attached
Multiple Units/ Apartments
Other
Number of Bedrooms:
Number of Bathrooms:
Laundry on Site:
Yes
No
Basic Monthly Resident Fee
Is Food included?
Yes
No
Additional Fees?
Property #4
Date residence was established:
-
Month
-
Day
Year
Date
Telephone Number
Contact Name
Street address
Street address line 2
City
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code
Property Ownership:
Please Select
Owns Property
Leases from Third Party
Leases from Related Person/ Entity
Other
E-mail
Is this property licensed by the State of Maryland to provide services for:
Mental Health
Substance Use Disorder
Behavioral Health
None of the Above
Other
List types of reasonable accommodations for persons with disability provided.
Number of Bedrooms:
Age Range:
18-24
25- 44
45-64
65+
Type of Structure:
Single Family Residence- 10 Beds or less
Multi-Unit Dwelling/ Apartments
Facility (Over 10 beds)
Population Served:
Women
Men
Co-Ed
Re-Entry
Medication Assisted Recovery (MAR)
Parents and children
LGBTQI
Youth (under 19 years old)
Senior Citizen (62+)
Laundry on Site:
Yes, Coin Operated
Yes, Included in Resident Fee
No
If leased, do you have written permission from property owner to operate a recovery residence?
Yes
No
Other
Number of Bathrooms:
Basic Weekly Resident Fee
Is Food included?
Yes
No
Additional Fees? Please be specific.
Property #5
Date residence was established:
-
Month
-
Day
Year
Date
Telephone Number
Contact Name
Street address
Street address line 2
City
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code
Property Ownership:
Please Select
Owns Property
Leases from Third Party
Leases from Related Person/ Entity
Other
E-mail
Type of Structure:
Please Select
Single Family-Detached
Townhouse/ Row House-Attached
Multiple Units/ Apartments
Other
Number of Bedrooms:
Number of Bathrooms:
Laundry on Site:
Yes
No
Basic Monthly Resident Fee
Is Food included?
Yes
No
Additional Fees?
Is this property licensed by the State of Maryland to provide services for:
Mental Health
Substance Use Disorder
Behavioral Health
None of the Above
Other
List types of reasonable accommodations for persons with disability provided.
Number of Bedrooms:
Age Range:
18-24
25- 44
45-64
65+
Type of Structure:
Single Family Residence- 10 Beds or less
Multi-Unit Dwelling/ Apartments
Facility (Over 10 beds)
Population Served:
Women
Men
Co-Ed
Re-Entry
Medication Assisted Recovery (MAR)
Parents and children
LGBTQI
Youth (under 19 years old)
Senior Citizen (62+)
Laundry on Site:
Yes, Coin Operated
Yes, Included in Resident Fee
No
If leased, do you have written permission from property owner to operate a recovery residence?
Yes
No
Other
Number of Bathrooms:
Basic Weekly Resident Fee
Is Food included?
Yes
No
Additional Fees? Please be specific.
**If your organization operates more than 15 recovery residences,
please contact Deborah McClung, Director of Volunteers/ Member Services at 443-629-7965 or
deborah@m-rocc.org
for special assistance.
Section IV: Administration/ Operations Information
(To help us assess and improve our Training and Technical Assistance curriculum, please answer Yes or No to the following questions.)
Does your organization carry general and/or professional liability insurance?
*
Yes
No
Does your organization comply with all State and Federal requirements? (If required; licenses/ certificates of occupancy are prominently posted)
Yes
No
Does your organization maintain an accounting system that fully documents all financial transactions between organization and residents, i.e. fees, payments, receipts and deposits?
Yes
No
Does your organization adhere to applicable confidentiality laws?
Yes
No
Does your organization have a written code of ethics?
Yes
No
Does your organization have a written policy and procedures manual?
Yes
No
Does your organization have a written grievance policy and procedures for residents?
Yes
No
Does your organization keep resident records secure with access limited to authorized staff only?
Yes
No
Does your organization abide by all local building and fire safety codes?
Yes
No
Please list three (3) of the most successful components/ strengths of your program/organization?
Please list three (3) areas that your program/ organization could improve?
Section V: Applicant Affidavit and Signature
*
Applicant hereby requests membership in the Maryland State Association of Recovery Residences (M-SARR) and is willing to fully participate in M-SARR sponsored events/ activities.
*
I have fully read, understand, and agree to abide by M-SARR established “Standards and Code of Ethics" policies
By checking the box below and submitting this application, I hereby attest that the above information is true and complete, and that I am authorized to execute this application on behalf of the applicant. This form is being submitted by
Membership Cost and Inspection Fees
prev
next
( X )
New Member
$
125.00
Reinstatement- Member
$
150.00
Inspection Fee- Per Bed
$
15.00
$15 Per Bed
Total
$
0.00
*
Please check the box in order to submit your application
Application and Recovery Residence Inspection payments are required prior to application review and can be made at this time through PayPal. Resident inspection fees are automatically calculated based on the type of structure and capacity of your organization. To complete your application submission with payment, click "Proceed to Checkout".
Save
Proceed to Checkout
Should be Empty: