Apply | Porter House Living - Intake Application

Complete Application

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Full Legal Name *

Date of Birth *

Gender

Government ID Available? *

Sobriety Date (approximate)

Primary Substance(s) of Use *

DetoxInpatient / ResidentialPHP (Partial Hospitalization)IOP (Intensive Outpatient)Outpatient CounselingPrevious Sober LivingNone

Are you on MAT (Medication-Assisted Treatment)? *

Do you attend AA/NA or other recovery meetings?

Probation/Parole Officer Name

PO Phone Number

Emergency Contact #1 Name *

Relationship

Emergency Contact #2 Name

Relationship

Treatment Provider / Case Manager Name

Organization

Reference Phone

Reference Email

I understand this is a drug- and alcohol-free living environment.I agree to random drug and alcohol testing.I agree to follow all house rules including curfew (10:00 PM Sun–Thu, 11:00 PM Fri–Sat). Overnight work exemptions are available with employer verification.I agree to attend mandatory house meetings.I agree to participate in recovery activities (AA/NA or equivalent).I agree to maintain employment, actively seek employment, or be enrolled in an educational program.I understand that violation of house rules may result in discharge.All information provided in this application is true and accurate to the best of my knowledge.