Ready to Take the Next Step?

Thank you for your interest in Hazel House. Please complete the form below, and a member of our team will reach out shortly to discuss your application and answer any questions.

Today's Date

First name

Last name

Phone

Birthday

Month

Day

Year

Current Address

Gender

Emergency Contact

Emergency Contact Relationship

Are you an alcoholic/addict?

Alcohol and/or drug of choice

Date last used

What is your current recovery plan?

Do you currently have a sponsor?

List any medical conditions

List any prescription medication you are currently taking

Have you ever lived in a sober living home?

If yes, please write which one and describe your reason for leaving

Are you involved in any legal action?

If yes, please explain

Are you required to register as a sex offender?

Have you ever been convicted of arson?

Have you ever been convicted of a felony?

If yes, please explain

Are you able to contribute to household chores?

Are you willing to attend a minimum of 5 supportive 12 step meetings per week?

Why do you want to live in Hazel House Sober Living?

What do you expect to receive from the program?

Are you currently employed?

Salary

How are you paid?

Name of person paying the bill (payee)?

Payee Phone Number

Housing needed by