• Application for Residency

    Please fill in the form below.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  •  -
  • Are you in jail or prison now?
  • Were you referred?
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you an alcoholic?
  • If yes, date of last drink
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you addicted to drugs?
  • If yes, date of last drug use
     - -
    2 digit month, 2 digit day, 4 digit year
  • Method of use
  • Have you previously been in any residential facilities?
  • Do you want to stop drinking alcohol and using addictive drugs?
  • Do you have support from sober family or friends to enter this type of program?
  • Are you employed?
  • Are you receiving disability, supplemental income or other non-job related income?
  • Do you have an occupational skill or trade?
  • If you don't have a job, are you willing to get one?
  • Do you need help getting a job?
  • What is your current education status?

  • Do you have any health problems that require special care?
  • Do you have a medical doctor?
  • Have you ever tried to commit suicide?
  • If yes, when?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you ever received mental health treatment?
  • If yes,
  • Are you currently receiving mental health treatment?
  • Do you take prescription drugs?
  • Do you have a mental health diagnosis?
  • Do you have any court cases pending?
  • Are you currently on probation or parole?
  • If yes, are you currently in compliance?
  • Do you have any outstanding warrants for your arrest?
  • Have you ever been convicted of a sexual offense?
  • Are you enrolled in the Recovery Works program?
  • If female, are you pregnant?
  • If yes, what is the due date?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Relationship status:
  • Is your partner clean and sober?
  • Do you have children?
  • Who are they currently living with?
  • If you are currently separated from your minor children, will you be having visitations?

  • Useful Telephone Numbers

    Family, Friends, Doctor, Etc.
  •  -
  •  -
  •  -
  • Are you a veteran?

  • By hitting the submit you agree to allow the staff of The Avenues Program to discuss my background and treatment with other professionals and agencies. I understand for the protection of myself and others there may be a need for the Board of Directors or the staff of The Avenues to check my legal standing and criminal background. I also understand that I am giving permission for the staff of The Avenues to contact any and/or all names and facilities on this application. I have read all the questions and answered them honestly. I agree to not use non-prescribed drugs, consume alcohol or violate the law while living at The Avenues. I agree to maintain gainful employment. I agree to stay current with my service fees. I agree to attend all required meetings and classes. I agree to participate in weekly house meetings and share regular house chores. I agree to these conditions because recovery from drug abd/or alcohol addiction is important to me.

  • Should be Empty: