Documents

Please click the following link to download the house rules

house rules_2024.v1

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? *

• Yes
• No

Phone Number *

Email *

Email

Confirm Email

Permanent Address *

Who Is The Best Person To Contact About This Application (Including phone number and/or email address)? *

Are You An Alcoholic? *

Date Of Last Drink? *

Are You Addicted To Drugs? *

Date Of Last Drug Use? *

List Of Drugs Used Addictively *

• Marijuana
• LSD
• Ecstasy
• Amphetamines
• PCP
• Benzodiazepines (Xanax, Valium, ect.)
• Fentanyl
• Cocaine/ Crack
• Opiates
• Heroin
• Meth
• Hallucinogens
• Other

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. *

• YES
• NO

Submit

View ABUSE AND MOLESTATION Policies