Application

Horizon House Residency Application

To become a resident of Horizon House, you must complete this form, and someone will contact you to schedule an interview. Please answer all fields truthfully, as the questions will determine your eligibility.

First Name

Last Name

Email Address

Contact Number

Full Mailing Address, City, State, Zip Code

Date Of Birth

How Did You Hear About Us

Are You An Alcoholic Are You An Alcoholic Yes No

If Yes, Date Of Last Drink?

Are You Addicted To Drugs? Are You Addicted To Drugs? Yes No

If Yes, Date Of Last Drug Use?

List drugs you use addictively

Do you attend NA/AA meetings? Do you attend NA/AA meetings? Yes No

If Yes, How Often Do You Attend?

Do You Want To Stop Drinking Alcohol/ Using Addictive Drugs? Do You Want To Stop Drinking Alcohol/ Using Addictive Drugs? Yes No

Do You Currently Have a NA/AA Sponsor? Do You Currently Have a NA/AA Sponsor? Yes No

If Yes, Please List The Name And Phone Number Of Your Sponsor

Are You Currently Employed? Are You Currently Employed? Yes No

If Yes, Who Is Your Current Employer?

Are You Receiving Welfare Or Any Other Non-job Related Income? Are You Receiving Welfare Or Any Other Non-job Related Income? Yes No

If Yes, From Whom Are You Receiving This Income?

If Currently Unemployed, What Is Your Plan Moving Forward Towards Gaining Employment?

What Is Your Total Monthly Income Right Now?

Do You Expect Your Monthly Income To Change In the Next 30 Days? Do You Expect Your Monthly Income To Change In the Next 30 Days? Yes No

Marital Status

Are You Currently On Probation Or Parole? Are You Currently On Probation Or Parole? Yes No

If yes, please list the name and phone number of your probation/parole officer

Do you take any prescription drugs that were prescribed to you? Do you take any prescription drugs that were prescribed to you? Yes No

If yes, list medications prescribed

Have you ever been to a treatment facility for alcoholism or drug abuse? Have you ever been to a treatment facility for alcoholism or drug abuse? Yes No

If yes, please list treatment provider, phone number, and counselor, if any.

Other Forms

Paper Application (DOC)

Resident Agreement 10-28-22 (DOC)

Guidelines agreement 10-28-22 (DOC)

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