Recovery Housing Contact List Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Recovery Housing Collaboration Partners and Stakeholders

Name of Your Business/Organization *

How many total homes/residences do you operate? *

Recovery Residences *

Please list ALL and include either the house name or address

City(ies) and County(ies) *

Please list city and county where you operate homes if you did not include an addresses in the list above

Primary Telephone Contact *

Number of Male Beds *

Number of Female Beds *

Website

Average cost per bed *

% of Fund Sources by Category

Please check all that apply

10%

20%

30%

40%

50%

60%

70%

80%

90%

All

None

Contract

Voucher

Resident Rent

Grants

Donation

Medicaid

Referral Sources

Please check all that apply

Corrections (DOC, County and City Jails, Drug Court)

Residential Treatment Providers

Outpatient Treatment Providers

Faith Based Organizations

Self Referral

Friend

Other

Community partners that deliver services to residents

Please check all that apply

Medical

Mental Health Provider

Substance Use Provider

Medication Assisted Treatment Programs

Training, Education, Employment

Connection to affordable housing

Other:

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of The Fletcher Group.

Does this form look suspicious? Report

Forms