Resident Application Form

Thank you for think about My Brother’s House as an option for your recovery. Please fill out the form entirely.

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

electronics attended Are

Email Address *

Phone Number *

If you do not have a phone number, the interview process can be significantly delayed.

Date of Birth

What are you suffering from (Select all that apply)?

• Alcoholism
• Drug Addiction
• Other

When was the last time you drank or used drugs?

Have you ever attended AA or NA meetings?

• Yes
• No

List any doctor prescribed medications you are currently taking

Do you have any medical issues?

Please describe any legal issues (parole, probation, warrants)

Are you a registered sex offender?

• Yes
• No

Do you have a source of income?

• Yes
• No

Are you physically able to work?

• Yes
• No

Do you have a state issued ID (Driver's License, ID Card, Passport?)

Will you bring a vehicle with you?

• Yes
• No

Are you willing to give up your personal electronics for a period of time?

• Yes
• No

Why are you wanting to try My Brother's House?

How did you find out about My Brother's House?

Submit