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Recovery Housing Contact List Form
Recovery Housing Collaboration Partners and Stakeholders
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Email
*
Your email
Name of Your Business/Organization
*
Your answer
How many total homes/residences do you operate?
*
Your answer
Recovery Residences
*
Please list ALL and include either the house name or address
Your answer
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
Your answer
Primary Telephone Contact
*
Your answer
Number of Male Beds
*
Your answer
Number of Female Beds
*
Your answer
Website
Your answer
Average cost per bed
*
Your answer
% 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
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:
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