Supervised Housing Application

Thank you for your interest in Herron Homes Supervised Housing.

Please take your time as you answer all questions completely.

When finished make sure to click on the submit button.

First name

Last name

Phone Number (Entering phone number and submitting application, allows for calls and texts related to employment)

Birthday

Month

Day

Year

Which facility are you currently located at?

Discharge Date

What is your drug(s) of choice?

How long have you used substances?

Have you ever been to rehab/detox?

Have you attended any programs that have helped in the past?

What do you think a sober living house is for?

Describe your past and current living situation?

What motivated you to want to participate in this program?

What plans do you have for your recovery?

What support do you plan to receive from our program?

Are you currently on probation or parole?

Have you ever been charged or convicted with a sex crime? If so, please elaborate.

Do you have any children?

What is your current relationship status?

What supports do you have in place right now?

Please list all medical diagnosis

Please list all mental health diagnosis

Please list all medications with dosage and frequency (fax list if necessary to 505-514-0732)

Is there anything else you would like us to know about you?

Please check all that apply:

I acknowledge that I have read the HH Supervised Housing Living Policy & Procedures.

I understand and agree to all HH Supervised Housing Policy & Procedures

I have questions about HH Supervised Housing Policy & Procedures

By signing below you agree that all information is true and correct to the best of your knowledge.

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