Square One DE Inc Application

First Name Middle Name Last Name

Area Code Phone Number

Street Address

Street Address Line 2

City State

Zip Code

Single Married Widowed Divorced Engaged Relationship

License Number

Street Address Line 2

State

Family/Friend Employer/Coworker Treatment/ Human services professional Online Courts/Judicial system

Less then a month One to three months Four to six months Seven months to a year More then a year

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.

High School Diploma GED Vocational College

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.

Date Hour Minutes AM/PM Option

Application & Residential Entry Form

Application Instructions