Resident Application

top of page

Home
About Us
- About Our Founder
Programs
- Referral Form
Transitional Housing
Get Involved
- Events at ETLS, Inc
- Giving Opportunities
Job Openings
Donate Now

ChatGPT Image Sep 10, 2026, 01_38_37 PM.png

Resident Application

Preferred Name(Required)

Legal Name(Required)

Address

Birthday(Required)

Month

Day

Year

Phone

Email Address

Preferred Method of Communication (Email, Phone or any other method)

Requested Move-In Date

Current Address / Location

Referral Information

Referral Source/Name

Referral Contact/Agency

Referral Source Phone / Email

Current Facility / Location, if applicable

Recovery & Support Information

Primary substance(s) that have created problems

Date of last alcohol / illicit substance use

Recent detox, residential, IOP, OP, or other treatment

Current treatment provider, if any (Provider's name, Counselor's name)

Current recovery supports / meeting / groups

Sponsor / peer/ recovery coach, if any

Medication, Medical & Behavioral-Health Information

MOUD/MAT, if any

Other prescribed medications

Current mental-health provider, if any

Current medical provider, if any

Medical / behavioral-health issue relevant to safe placement

Reasonable accommodation requested? (Required)

Yes

No

Please describe the accommodation request.

Community Stability

Employment Status

Employed

Seeking

Student/Training

Disability/Benefits

Other

Employer / School / Training Program

Work / School Schedule

Monthly Income Amount

Funding Source

Transporation Plan

Vehicle Information, if applicable (Make, Model, Color & Tag Number)

Court / Probation / Parole Information

Currently under Court / Supervision involement?

No

Yes - Probation/Parole/Drug Court/Reentry Court/TASC/Other

Supervising /Referring Agency

Officer / Case Manager / Court Contact

Contact Phone / Email

Upcoming Court / Review Date(s)

Court / Supervision requirements affecting residency

Legal restrictions affecting this residence/location

No

Yes

If yes, explain:

Current Housing & Placement Need

Current Housing Situation

Homeless/Unsheltered

Family/Friend

Shelter

Residential Treatment Facility

Correctional Facility

Other

Why are you seeking recovery housing now?

Have you lived in recovery/sober housing before?

No

Yes

If yes, where/when:

If you left a prior recovery residence, what led to your departure?

Residency Fee/Funding

Expected source of monthly resdiency fee

Funding details / contact, if applicable

Do you anticipate difficulty paying the residency fee?

No

Yes

Unsure

If yes, explain:

Applicant Goals

Goal 1

Goal 2

Goal 3

Success & Support

What will help you remain successful in recovery?

Challenges/barriers you expect while in recovery housing

What would you like ETLS staff to know about how to best support you?

Anything else you want ETLS to know and consider?

ETLS Welcome T-Shirt

T-Shirt Size

Each new resident receives one complimentary ETLS T-shirt at admission

Application Certification

I certify that the information I provided is accurate to the best of my knowledge. I understand that completing this application does not guarantee admission. ETLS will make an individualized determination regarding whether ETLS can safety and appropriately meet my needs. I understand that additional screening and separate admission documents will be requried if I am accepted or conditionally accepted.

Applicant Signature(Required)

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Applicant Name

Date

Month

Day

Year

bottom of page