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.

Document

Applicant Name

Company

First Name*

Last Name*

Date of Birth*

Last 4 of SSN*

Phone*

Applicant Email*

Current Address - the last place you lived before entering treatment

Country

Address Line 1*

Address Line 2

City*

State*

Zip Code*

Please indicate if you are seeking male or female housing*

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

Counselor First Name*

Counselor 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*

Do you have children?*

Marital Status: S/M/D*

Military Service*

charged/convicted on a violent crime

charged/convicted of a sex offence

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?*

Do you need help finding an outpatient provider?*

Additional Info

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*

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