Recovery House Application

If you CANNOT fill out this online application, please call us at 207-701-1182. If applicant is incarcerated, we encourage them to have a case manager, a friend, or a family member fill out the application on their behalf.

We look forward to reviewing your application. Please make sure you leave us a phone number that has voicemail set up. Thank you.

Full Name(Required)
MM slash DD slash YYYY
dd/mm/yyyy
Address

Name, Phone Number, & Relation
MM slash DD slash YYYY
Past Treatment Programs
City/State
Counselor Name
Entry/Exit Date
 
Have you ever lived in a sober house?(Required)
Substance Use(Required)
Drug
Length of Abuse
Time Since Last Use
 
Current Medications and Dosage(Required)
(Required)
Signature
Date
Recovery Housing Application Fields marked with an * are required