Square One DE Inc Application

First NameMiddle NameLast Name

Area CodePhone Number

Street Address

Street Address Line 2

CityState

Zip Code

License Number

Street Address Line 2

State

My own home/apartment.Someone else’s home/apartment.In a medical, treatment, or other residential recovery setting.In jail, prison, or other correctional setting.In a shelter or other temporary housing facility.Outdoors or on the streets.

Square One DE Inc. CANNOT accept applicants on METHADONE or SUBOXONE maintenance programs.

BY SIGNING THIS APPLICATION,
you have honestly answered the above questions to the best of your knowledge. You understand the stipulations, guidelines, and provisions as stated in the Operational Rules and Procedures and agree to abide by them. You also agree to submit to a necessary probationary period. In the event that you are approved for entry into a Square One house and you violate your terms of probation, you herein agree to leave Square One properties without drama or resistance.
I have read all the material on this application form including the Operational Rules and Procedures setforth. I have also answered each question honestly and want to achieve recovery from alcoholism and/or drug addiction without relapse.

DateHourMinutesAM/PM Option

Application & Residential Entry Form

Application Instructions