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Home
Recovery Center
Application
Thrift Store Donations
- Florida Schedule a Pick-Up
- Tennessee Schedule a Pick-Up
Shop
Service Areas
Donate
- Cars GIVE Life
Blog
Contact

Schedule a pick up

Home
Recovery Center
Application
Thrift Store Donations
- Florida Schedule a Pick-Up
- Tennessee Schedule a Pick-Up
Shop
Service Areas
Donate
- Cars GIVE Life
Blog
Contact

Menu

Home
Recovery Center
Application
Thrift Store Donations
- Florida Schedule a Pick-Up
- Tennessee Schedule a Pick-Up
Shop
Service Areas
Donate
- Cars GIVE Life
Blog
Contact

Haven House Application

Application

Please, give us the opportunity to make a positive admissions decision by answering all questions thoroughly and completely.

NOTE: Applications that are not thorough and complete will be rejected.

Page 1 of 4

If a required field does not apply, enter NA.

Which program are you applying for?(required)

First Name(required)

Middle Name(required)

Last Name(required)

Date of Birth(required)

Generational Suffix

Address(required)

City(required)

State(required)

Zip code(required)

Phone Number(required)

Email Address(required)

Marital status:(required)

Single

Married

Separated

Divorced

Widowed

Are you:(required)

An Alcoholic

Chemically Dependant

Other

What drugs have used in the past 3 years?(required)

Have you been through a rehabilitation facility? (required)

Yes

No

What Rehab have you been to and where is it located?

Date of last drink or drug?

Have you ever attended AA (Alcoholics Anonymous) or NA (Narcotics Anonymous)?(required)

Yes

No

When did you attend your first AA or NA meeting?

How many meetings do you attend per week?

Do you currently take or need prescription drugs?(required)

Yes

No

Explain in DETAIL what prescription drugs you take and why.

Do you have any current medical conditions or needs?(required)

Yes

No

List medical conditions requiring special attention.

Give a COMPLETE history of your chemical dependency.(required)

In DETAIL describe your current situation and reason for seeking help.(required)

Reminder: We will keep confidential and not release the following financial and employment information.

Are you currently employed?(required)

Yes

No

List your current employer.

What and how much is your current source of income?(required)

Have you ever been arrested?(required)

Yes

No

Give a DETAILED explanation of all arrests.

Do you have a court case pending?(required)

Yes

No

Court Date

What is/are the charge(s)?

How many times have you been arrested?

What was/were the charge(s)?

Have you ever been convicted of a misdemeanor? (required)

Yes

No

Explain in detail the misdemeanor conviction(s):

Have you ever been convicted of a felony? (required)

Yes

No

Explain in detail the felony conviction(s):

Are you on probation?(required)

Yes

No

Please list why you’re on probation and your probation officer's name, county and phone number:

Are you on parole? (required)

Yes

No

Please list why you’re on parole and your parole officer's name, county and phone number:

Are your probation/parole fines and fees current?

Yes

No

How much are your fines and fees?

Do you have any warrants for your arrest outstanding? (required)

Yes

No

Explain outstanding arrests:

Have you ever been arrested or convicted as a sex offender? (required)

Yes

No

Explain sex offender arrest or conviction:

Reminder: The following statements are confidential and will not be released to any third parties.

I have read the item above and by typing the LAST FOUR DIGITS of my Social Security Number on this page, I understand it is considered a digital signature and understand that if accepted in HAVEN HOUSE, I agree and subject myself to all rules and regulations both present and future, including the waiver of any landlord-tenant rights I might have as respect to residency in HAVEN HOUSE. The nature of HAVEN HOUSE requires expulsion, without notice or refund, of any resident who is found to be using alcohol, drugs, or both.

IF ACCEPTED, YOUR SIGNATURE WILL BE REQUIRED AGAIN UPON ARRIVAL!"

ENTER THE LAST FOUR DIGITS OF YOUR SSN(required)

This field should be left blank