Recovery House Application

Welcome to Phoenix House Recovery and Reentry Center, where we provide comprehensive support for individuals overcoming substance use challenges. Our dedicated team is here to guide you on your journey to recovery and wellness

If you CANNOT fill out this online application, please call us at (207) 509-0000. 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. You will hear from us within 72 hours. Please make sure you leave us a phone number that has voicemail set up. Thank you.

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What is your full legal name: *

First

Last

We are a Maine Association of Recovery Residences Level 3. We mandate treatment as a part of our program. Upon screening clinical services will determine the level of care you belong in. This includes IOP, individual counseling, and/or group therapy. Do you agree to participate in the level of care that clinical services determines you belong in?  (copy) *

• Yes
• No

Have you ever committed a sex offense or are you on the Sex Offender registry? *

• Yes
• No

Current. housing status *

• In a detox, rehab, or mental health facility
• In my own home or apartment
• Incarcerated
• In a homeless shelter
• Unsheltered / sleeping outside
• Staying with friends or family
• Other (please explain below)

When would you like to move in? Have a deadline? *

Be as detailed as possible, and explain your current location / living situation. ANY false or inaccurate answers in this application are grounds for your immediate denial or discharge from the program. Answer all questions throughly.

Date of Birth *

Are you currently in or seeking recovery? Yes or no? If yes, why? Be as detailed as possible. *

4-5 sentences

Why do you want to live in a recovery house? What is your goal in the next 30-60 days? *

Are you willing to attend AA, NA, SMART Recovery, counseling, church, etc. 3x / week? (copy) *

• Yes
• Neo

substance of Choice *

• Alcohol
• Heroin/Fentanyl
• Cocaine
• Meth
• PCP
• Benzos
• THC
• Other

How long have you been using and how much / how frequently do you currently use? OR how much did you used to use and how long have you been in recovery? *

Be as detailed as possible

Are you willing to attend AA, NA, SMART Recovery, counseling, church, etc. 3x / week? (copy) *

• Yes
• Neo

What do you do to remain abstinent from substances? Be as detailed as possible. *

Last or Current Address *

Country

Address Line 1

Address line 2

City

State

Zip Code

Mostly Income $ *

Type of income *

• Employment
• SSD/I
• Unemployment
• Other

How will you occupy your time at Phoenix House Recovery and Reentry Center? *

• Work 40 hours per week or more
• Work between 20 and 40 hours per week
• Work less than 20 hours per week
• Will not work, but will enroll in school and/or volunteer substantially
• None of the above

Will you be able to afford $700/month? If not, what scholarship / funding sources have you checked with? How will you pay? Phoenix Recovery and Reentry Center endeavors to meet ALL residents where they're at, and we will always do what we can to help residents overcome financial challenges. *

Two references' names and phone numbers

You MUST provide two of these, preferably three. Do not list any Phoenix Recovery and Reentry Center staff and do not list family..

Do you have any medical condition(s)? If yes, what? *

Do you have any disabilities and/or difficulties with activities of daily living? *

Do you take any psychiatric medication(s)? If yes, medications and doses: *

Do you have a primary care physician? If so, name and contact info: *

Do did How

Are you on any community supervision? *

Drug Court, Probation, Parole, Pretrial, etc. If so, please provide department and contact info:

Your Email address *

Your Phone number *

How did you hear about us? Be as detailed as possible (name, location, etc.): *

If law enforcement, treatment, healthcare, or other service provider, please explain.

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