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Resident Application

Resident Information

Your First Name*
Please let us know your name.
Your Last Name*
Please enter your last name.
Your Email
Please let us know your email address.
Your Phone Number*
Please enter phone number.
2nd Phone Number
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Mailing Address*
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Birthdate* / /
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Emergency Contact Information

Emergency Contact First Name*
Emergency first name
Emergency Contact Last Name*
Please enter your emergency contact last name.
Emergency Contact Phone*
Please enter phone number.
   

Have you been a prior resident at Push Forward Recovery Centers?

Prior Resident?*
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Date Started at PUSH
Choose date
What date did you start at Push Forward Recover Center?
Date Ended at PUSH
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Were you able to maintain sobriety?*
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Sober House and Payment Selection

Move In Date*
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Select Sober House*
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Payment Source*


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Select all that apply
Payment Source Name*
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If your payment source is family or friend please enter their name.
Payment Source Phone*
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Payment Method*

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Please select all ways that you plan on making payment.
   

Addiction Information

Alcohol or Drug of choice?*
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Date of last use?*
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Prescribed Medications*
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Are you involved in any legal matters?*
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List felony convictions*
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List any felony convictions or type "none"?
List misdemeanor convictions*
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List any misdemeanor convictions or type "none"?
Current status of convictions/misdemeanors?*
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Please provide the status of any convictions/misdemeanors? i.e: "on parole, parole officer name..."
Under the influence during crime?*

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Were you under the influence of drugs/alcohol when you committed this crime?
   

Agreements

I agree to remain clean and sober at all times.*
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Please initial (first and last name initials)
I agree to pay my resident fee in advance.*
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Please initial (first and last name initials)
I agree to keep Push Forward Recovery Center Houses free from alcohol and illegal drugs at all times.*
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Please initial (first and last name initials)
I agree to enter into a resident behavioral contract (following all resident rules for structure and accountability) and abide by the terms.*
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Please initial (first and last name initials)
*
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I certify that All information I have provided to Push Forward Recovery Center is true and correct. I have read all material on this application form including the limitations above. I have answered each question honestly and want to achieve long-term sobriety from alcoholism and/or drug addiction. When I am accepted and take residency, I agree to hold harmless Push Forward Recovery Center, the property owners and any and all service providers.
Signature*
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Please type your full name.
Application Fee
$35 non-refundable application fee
Total

about the HOUSES

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Oro Blanco - Women's House