Resident Application Form

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

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Name *

First

Last

Best way to contact you (phone number, email address) *

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

issues Card, (Driver's

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