Application for Residency Application for Residency 2026 Your Information Legal Name * Birthdate * Email Phone * Current Address * Current Address Street Street Current Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Date of Last Use * Drug of Choice * Date you need a bed * How do plan on paying for sober living? * Do you have any legal Issues? * Yes No Describe the legal issue. * Do you have any current medical conditions? * Yes No Explain the medical condition. * Please list all medications (prescription & over the counter). * Are you currently in treatment? * Yes No Expected discharge date. * Treatment Facility * Treatment Contact Person * Treatment Contact Phone * Do You Have a Valid Driver’s License? * Yes No License # * Do You Have a Car? * Yes No Make/Model of Car * Emergency Contact Emergency Contact Name * Relationship * Emergency Phone * Emergency Contact Address * Please answer the following questions fully, your responses help us to determine whether you will be a good fit for Mission House. Thank you !! General Application Information 1.Why are you applying for sober living? * 2. We have a zero-tolerance policy on substance use. We conduct random Breathalyzers and urine drug screening, you have up to two hours to complete test, if a test is avoided or refused, it will be considered an admission of guilt and you will be discharged immediately. What are your thoughts about this policy? * 3. Mission House requires its residents to be active in a 12 step program, work the steps, obtain a sponsor, and attend a minimum of three 12 step meetings per week. What are your thoughts about this policy? * 4. Residents are required to work, volunteer or go to school for 32 hours per week. Residents are also not to work over 45 hours per week, recovery needs to be your focus not money. Will you have a problem with this policy? * 6. The curfew for the first thirty days is 9 pm, after thirty days it extends to 10 pm. Overnights can be requested after your first 30 days and are usually approved if all house requirements are being met. What are your feelings about this policy? * 6. The curfew for the first thirty days is 9 pm, after thirty days it extends to 10 pm. Overnights can be requested after your thirty day trial period and are generally approved if you are meeting all other requirements. What are your feelings about this policy? Will this be a problem for you? * 7. We require a three month minimum commitment, will this be a problem for you? * 8. Rent is $850.00 a month and includes all utilities, internet, Netflix, bathroom and kitchen supplies. The total move in cost is $1250.00. This amount includes the first months rent and a $400.00 refundable security deposit. Security deposit is returned to residents when they move out, unless they fail to give 2 weeks notice, fail to stay for 90 days, or have done damage to property. Failure to pay rent when due without making prior arrangements is a cause for discharge. How do you plan on paying rent? * 9. We respect healthy long-term relationships. Are you currently in a relationship? * Yes No Does this person use substances? * Yes No If you are not currently in a relationship will you agree to not enter a new relationship while in the house? * Yes No Romantic relationships within the house is prohibited and will lead to discharge? What are your feelings about this policy? * 10. We are not equipped to take women with serious mental health issues, such as: self harm or suicidal ideation. If you are diagnosed with a mental health disorder please note it here. * 11. Disruptive behavior by any resident will not be tolerated. These behaviors include verbal or physical altercations. Destruction of property, theft, dishonesty, or disrespect. These behaviors will lead to immediate dismissal. Residents will also be held legally and financially responsible. What are your feelings about this policy? * Do you have any final thoughts or concerns? Signature signature keyboard Clear Today's Date Submit Application If you are human, leave this field blank.
