House of Pearls Resident Application
To enter the House of Pearls, you must complete this application in full.
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Today's Date *
Today's Date
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First and Last Name *
Date of Birth *
Date of birth
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Home Address *
Complete home address, including street or PO box, city, state, and zip.
Email *
Phone number *
Education Level *
Required
Marital Status *
Required
Where was your last residence? *
Do you have a current, valid driver's license or state issued identification card? *
Contact Name *
Contact Relationship *
Contact Phone Number *
Why do you want to come to House of Pearls? *
How did you hear about House of Pearls? *
When did you have your last drink or drug? What was it? (You must be drug free at least 72 hours. All residents are subject to drug testing.) *
Do you have any court dates pending? *
If you have court dates pending, please explain.
Have you ever been convicted of a sexual offense? *
Are you on parole or probation for anything? *
If you are on parole or probation for anything, please explain.
If you have a parole officer, please provide the name and phone number.
If you leave House of Pearls for any reason, we will notify the proper authorities (PO, etc.).
Do you have a prior criminal record? *
Do you have a felony conviction? *
If you have a prior criminal record or felony conviction, please explain.
Rules and Expectations
The use of illegal chemicals, alcohol, or the misuse of prescription drugs will result in the immediate termination of any agreement between House of Pearls and yourself. You will be required to leave the property immediately.

Upon your entrance into House of Pearls, you will be given a set of the overall house rules. It is your responsibility to know these rules. You will be held accountable for them. If you do not understand any or all of these rules, it is your responsibility to ask for clarification.

You are required to work on daily work projects. These work projects are designed to produce discipline and responsibility and are not a source of income.

Do you agree with all of the rules and expectations? *
Our program is one consecutive year and we expect you to make a firm commitment to complete it. Is there anything, including finances, that would prevent you from doing this? *
If yes, please explain.
We are a smoke free facility. Do you agree to refrain from any and all tobacco and/or vaping while a resident at HOP? *
What is your drug of choice? *
Under no circumstances do we allow narcotics, anti-psychotics or controlled substances while a resident of HOP. List all medications you are currently taking. *
House of Pearls does not pay for medication but will provide you with information for assistance with medication. If you are currently taking any medications not allowed at HOP, you will need to detox from them before coming with the consent of the Dr. who ordered them.
List any allergies or medical problems. *
How would you rate your health? *
Prior to admission, all persons with disabilities must submit a current medical record from her doctor, stating limitations of disability .
Required
When were you last in the hospital?
Why were you there?
Have you been diagnosed with hepatitis or HIV? *
If yes, when? Give details.
Are you pregnant? *
House of Pearls is not a medical facility and cannot care for a pregnancy or house an infant.
Are you willing to submit to the following tests prior to entering House of Pearls? *
Check the tests you are willing to submit to.
Required
Do you agree to the rules for clothing and personal belongings? *
Are you willing to persevere and do what it takes to change your life? *
Have you ever been to House of Pearls in the past? *
If so, please explain reason for leaving.
What area (i.e. addiction, suicidal ideation, eating disorders, mental health, trauma etc.) are you struggling with and for how long? * *
Click or tap the Submit button below to send your resident application.
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