Apply to The Core Transitional Housing

Please fill out the form below to be considered for residency. All information is kept confidential. You can also download the application if you'd prefer to print and complete it by hand.

Full Name Date of Birth Social Security # Phone Number Email Emergency Contact Name Emergency Contact Phone Relationship to Emergency Contact Current Living Situation How long have you been there? Reason for Leaving Do you have a safe place to go if not accepted? If yes, where? Primary substance(s) used Date of last use Sobriety Date Have you ever overdosed? If yes, when? Do you currently attend recovery meetings? Meeting Frequency Sponsor or Mentor? Medical Conditions or Disabilities On Medications? List Medications Mental Health Diagnosis Currently Seeing Counselor? On Probation or Parole? Probation Officer Contact Info Upcoming Court Dates? If yes, when and where? Convicted of Violent or Sexual Offense? Explanation if yes Currently Employed? Employer & Position Weekly Income How will you pay program fees? Receiving Financial Assistance? Describe Assistance Why do you want to live in a recovery residence? Willing to follow rules and remain abstinent?