Residential Application Apply Now

Residential Application

The application takes 20-40 minutes to complete.
Please ensure you have the following information before you begin, as progress cannot be saved:

Family Summary

Addiction History

Prostitution History

Abuse History

Health History

Arrest History

Education and Work History

    First Name *

    Last Name *

    Email *

    Phone Number

    Address

    Date of Birth

    Name of Emergency Contact & Relationship

    Phone number for Emergency Contact

    Referred By:

    Tell us about yourself

    Please Describe your Relationship with your Family

    Do you have Children?

    Do you have a history with addiction?

    Do you have a history with prostitution or sex trafficking?

    Do you have a history with Sexual Abuse?

    Have you experienced domestic violence?

    Are you currently in a romantic relationship?

    Do you have any geographical limitations

    Yes - FloridaYes - Other StatesNo

    Health Questions - please check any box that is YES

    List any inpatient, A&D Treatment, IOP, and/or recovery programs in which you have ever participated.

    ARREST HISTORY - Do you have any pending charges or warrants?

    Are you on Probation?

    What is your highest level or Education?

    Please describe your work history

    What time of day is best to contact you?