Just Living Recovery Application

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A Queer-Friendly Intentional Recovery Community

Full Legal Name *

Preferred Name, if different from above

Date of Birth *

YYYY

Sober Date *

YYYY

Desired Move In Date *

YYYY

Pronouns *

She/Her

He/Him

They/Them

She/They

He/They

Other:

Required

LGBTQ?

Gay

Lesbian

Bisexual

Transmale

Transfemale

Queer

Cisgender

Prefer not to say

Other:

Clear selection

Race (Select all that apply) *

Asian/Asian American

Black or African American

Native Hawaiin or Other Pacific Islander

American Indian or Indigenous or Alaska Native

White

Unknown

Other:

Required

Hispanic or Latino

A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Yes

Phone Number *

Email *

Schedule Contact Information, if different from above (i.e parole officer, probation officer, relative, etc). Include Name, Phone Number and/or Email. This is required for all DOC applicants.

Emergency Contact *

Referred By (Name and Agency):

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