Documents

Please click the following link to download the house rules

House Rules

Please click the following link to download an application PDF or fill out and submit the provided form below

Application for Residency

Name *

First

Last

Date Of Birth *

Have You Been Vaccinated Against COVID-19? *

Phone Number *

Email *

Confirm Email

Permanent Address *

Are You An Alcoholic? *

Date Of Last Drink? *

Are You Addicted To Drugs? *

Date Of Last Drug Use? *

When Did You Attend Your First AA or NA meeting? *

How Many AA/ NA Meeting Do You Now Attend Each Week? *

Are You Employed? If So, Who Is Your Employer? *

What Is Your Current Monthly Income? *

Place(s) Of Residence During The Past 2 Years *

Do You Have Medical Insurance? If so, Please Provide Name Of Insurer *

Please Provide Names And Contact Info For The First Reference Who Can Vouch For Your Commitment To Recovery *

Please Provide Names And Contact Info For The Second Reference Who Can Vouch For Your Commitment To Recovery *

Have You Ever Been To A Treatment Facility For Alcoholism Or Drug Addiction? If So, List The Treatment Provider *

Do You Take Prescription Drugs? If Yes, List The Drugs, Dosage, And The Reason The Drug Has Been Prescribed *

Do You Currently Have Any Physical Or Mental Health Issues (Including Depression, ADD, And Anxiety)? If So, Please Describe. *We Reserve The Right To Request A Mental Or Physical Evaluation *

Have You Ever Been Charged Or Convicted Of A Felony? Are You On Probation, Parole, Or Have An Upcoming Court Appearance? If So, Please Describe The Circumstances, Charges, And/ Or The Outcome *

Name Of Last Education Institution Or School Attended *

Do You Have A Drivers License? In What State? *

Are You Married? If So, Name Of Spouse *

Fathers Name, Address, Phone Number, Email Address *

Mothers Name, Address, Phone Number, Email Address *

Emergency Contact - Name, Relation, Phone, E-mail *

Back-up Emergency Contact - Name, Relation, Phone, E-mail *

What Are Your Short Term Goals? *

What Are Your Long Term Goals? *

Why Do You Think Residing At Mikes Place Could Help You? *

What Other Information Is Relevant To This Application? *

APPLICANT ACKNOWLEDGEMENT: I understand that if my application is accepted, I will comply with Mike's Place House Rules and Policies statement (Which I have been given the opportunity to read). I understand that these Rules and Policies may change from time to time at the discretion of Mike's Place. I further understand that my residency with Mike's Place is temporary and transitional. I acknowledge that, as a resident at Mike's Place, I am a licensee and not a tenant, and that I have no tenancy rights or interest. As such, I agree that I can be discharged from the premises immediately should it be determined by the Group Manager or a Director (at their sole discretion) to be in the best interest of the house and/ or other house members. Should I refuse to leave the premises immediately upon discharge, I acknowledge that I will be considered to be a trespasser and that the local police department will be called to escort me off the property. I have answered each question honestly and I want to achieve recovery from alcoholism and/ or drug addiction without relapse. *Selection of YES or NO shall serve as the applicants signature for agreement/ understanding of the above statement. *