What is your full legal name?
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First Name
Last Name
Which house are you applying to?
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Current housing status
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When would you like to move in? Do you have a deadline?
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Be as detailed as possible, and explain your current location / living situation.
Date of Birth
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MM
DD
YYYY
How do you identify your Sex and pronouns (they, he, she, etc.)
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By checking this box, I acknowledge that I have read and agree to abide by the Participant Agreement
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located at journeyhousemaine.com/contract
Are you currently in or seeking recovery? Yes or no? If yes, why? Be as detailed as possible.
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4-5 sentences
Why do you want to live in a recovery house? What is your goal in the next 30-60 days?
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Substance of Choice
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Are you willing to attend AA, NA, SMART Recovery, counseling, church, etc. 4x / week?
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What do you do to stay sober? Be as detailed as possible.
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Last or Current Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Type of income
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How will you occupy your time at Journey House?
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Do you have the full $700 ($500/mo + $200 deposit) to move in? *NOTE this is $600/mo + $200 for South Portland). IF NOT, what scholarship / funding sources have you checked with? How will you pay?
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Your application will not be considered unless you have the funds to move in or you have made EVERY EFFORT to obtain the funds. If you do not have the funds, then here you must detail SPECIFICALLY which sources (churches, caseworkers, the courts, PO, friends, family, etc.) you have discussed payment with, what they have said, and how much they are able to help pay. It costs $100/day to incarcerate you, and even more for a shelter or hospital, so it is in the best of POs and medical staff, etc., to find you this money. Scholarships are very limited, and you will not be considered for one if you submit a short or otherwise inadequate answer.
Two references' names and phone numbers
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You MUST provide two of these, preferably three. Do not list any Journey House staff and do not list family
Do you have any medical condition(s)? If yes, what?
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Do you have any disabilities and/or difficulties with activities of daily living?
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Do you have any co-occuring disorder(s)? If yes, what?
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Do you take any psychiatric medication(s)? If yes, medications and doses:
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Do you have a primary care physician? If so, name and contact info:
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Do you have any felony convictions? If so, what and when:
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If yes, please list the charge(s) and the conviction dates. Criminal history will not necessarily disqualify you.
Are you on any Community Supervision?
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Drug Court, Probation, Parole, Pretrial, etc. If so, please provide department and contact info:
Emergency Contact
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Name, relationship to you, and phone number
Your email address
Your phone number
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(###)
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What are some dates and times that work for us to call you on the number you have provided?
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By typing my name here and clicking the submit button below, I affirm that the typed name serves as a legally binding signature, that all the facts above are accurate, and that my relationship with and expectations of Journey House will occur as laid out in the Participant Agreement.
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