R3House, LLC Admission Application

Please complete the form below to apply for residency at one of our sober living homes

R3House LLC is an equal opportunity support housing provider and does not discriminate based on ethnicity or race, religious beliefs, sexual orientation, education or substance addiction. However, for the safety of our community, we do not accept violent criminal offenders and sexual offenders.

Applicant Name

First Name

Last Name

Date of birth

YYYY

Last 4 of SSN

Phone

(###)

###

####

Applicant Email

Current Address - the last place you lived before entering treatment

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact - Blood Relative or Spouse

Emergency Contact Name

First Name

Last Name

Emergency Contact Relationship

Emergency Contact Phone

(###)

###

####

Emergency Contact Email

Current Treatment Facility

Projected Treatment Completion Date

Counselor Name

First Name

Last Name

Counselor Phone

(###)

###

####

Counselor Email

Aftercare Case Manager

First Name

Last Name

Case Manager Phone

(###)

###

####

Case Manager Email

Education / Employment /Skills /Marital Status

Work History

(Last Two Jobs)

Do you have children?

Yes

Marital Status: S/M/D

Military Service:

Have you ever been charged/convicted on a violent crime?

Yes

Have you ever been charged/convicted of a sex offense?

Yes

Current Pending Charges:

Probation/Parole Officer Name

First Name

Last Name

Probation/Parole Officer Email

List Previous Treatment Centers and Dates (Last 3):

Willing to attend outpatient treatment?

Yes

Recovery Goals

List current prescription medications below

Funding Source - ex: family, friend, self pay

Disclaimer

R3House LLC has a zero-tolerance policy towards the use of drugs, alcohol, any mood or mind altering substances, and gambling. Residents are required to disclose all current and planned prescription medications to our staff. Residents will fill out a complete list of all medications prescribed to them. Residents found with prescription medication that is not prescribed to them are in violation of R3 House Rules. Residents are responsible for administering, refilling, and storing their own medications. R3House provides safe storage for MAT medications, residents who are prescribed MAT are responsible for following the prescribed protocol as directed by their physician. Residents who are prescribed MAT are responsible for refilling their medications, any changes to prescriptions including tapering or ceasing MAT must be communicated in writing to R3 Staff. R3House, its employees, management, and volunteer staff, are not responsible for refilling, or managing our residents’ medications.

Consent

I give R3House LLC and its staff permission to view, evaluate, and discuss this application with my treatment counselor/therapist in order to evaluate my qualification to stay at the R3House. I give R3House LLC and its staff permission to share this application with R3 Recovery Services. I give R3House LLC and its staff permission to discuss my treatment plan with my emergency contact.

Digital Signature

First Name

Last Name

Date

YYYY

R3House, LLC Admission Application

Please complete the form below to apply for residency at one of our sober living homes

Text or Call Now to Reserve a Space in Our Sober Living Homes in Lancaster, PA:

(717) 601-2555