Appendix A - LOTUS RECOVERY HOUSE - RESIDENT APPLICATION FORM

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Male or Female *

Male

Female

Application date: *

YYYY

First name: *

Last name: *

Date of Birth: *

YYYY

Current residential address: *

City *

State *

Zip Code *

Telephone number to be reached at : *

How long have you been sober from alcohol and/or other drugs? *

Substance of Choice (select all that apply): *

Alcohol

Marijuana

Prescription Pills - Oxycodone

Prescription Pills - Percocet

Heroin

Fentanyl

Suboxone/Subutex

Cocaine

Methamphetamines

Amphetamines

Stimulant Based ADHD Medications (Adderall/Ritalin)

Ecstasy

MDMA/Molly

K2 Spice

Bath Salts

Xanax

Valiumm

Klonopin

Phenobarbitol

Hallucinogens

Inhalants

Over the Counter Medication

Other:

Required

Are you currently receiving substance abuse treatment? *

Yes

Are you currently on medication assisted treatment? *

Yes

Do you have any children under the age of 18 that currently live with you? *

Yes

Are you a registered sex offender? *

Yes

Have you ever been charged with a sex offense? *

Yes

Have you ever lived in a Recovery House? *

Yes

Are you employed? *

Yes

Do you have the ability to pay rent? ($80 per week) *

Yes

Please describe your current living situation: *

How could you provide peer support and or mutual aid to other residents? *

Would you engage in developing a recovery plan and update it as needed? *

Yes

The Lotus Recovery House (LRH) provides an alcohol and drug-free living environment, peer support and connection to recovery assistance for women ages 18 and over with substance use disorders. The LRH is a recovery-focused, safe, clean and sober living environment for the women who reside in the home. The LRH collaborates with multiple community partners to assist residents in strengthening their sobriety and in building recovery-based lives. Staff and volunteers interact with residents and activities are designed in a way to support a life in recovery. Discussions about recovery plans, relapse, prevention, and living life in recovery are expected. These rules and handbook are designed to support residents in their recovery process while residing at the Lotus Recovery House.

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This form was created inside of Mental Health and Recovery Services Board of Seneca, Sandusky and Wyandot Counties. Report Abuse

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