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Coordinated Recovery Application
Fill out this form to give us a head-start on your transition to one of our houses.
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First and Last Name
*
Your answer
Email address
*
Your answer
Phone number
*
Your answer
Are you willing to make a commitment to stay at the house for at least 6 months?
*
Yes
No
Maybe
Do you have health insurance?
Commercial plan
Medical Assistance
PMAP (Medical Assistance Managed by an insurance company like BCBS)
No insurance
Other:
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Anything else you think we should know?
Your answer
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