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Application form

Recovering Gracefully Homes Application
216 East Georgia Ave Ruston, LA 71270
Please provide the following information for use by Recovering Gracefully Homes in assessing eligibility into our home(s). Disclosure of criminal records will not disqualify you. Type or print all information.

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Name

FirstMiddleLast

Date of BirthSocial Security Number

Are you currently homeless / without a permanent place to live?

Current Address

Address Line 1CityState / Province / RegionPostal CodeCountry

Telephone numbers:Email

Do you have transportation?

Your sobriety date ( If Applicable )What is your drug of choice(s) ( If Applicable )If you have been in a substance abuse treatment, either in-patient or out-patient within the last three years, give the name of each program (i.e. detox, treatment center, halfway house),the dates you attended, and the reason for leaving

Do you currently participate in self-help

Name of program (s)How many meetings do attend per week?Name Of Meetings

Name

FirstLast

Do you have a sponsor: _If no, why not:What is your current source of income?Employment Disability payments of $ per monthOther ExplainJob descriptionWeekly net income: $How long thereList sources and amounts of other weekly income:

What is your marital status

Single
Married
Separated
Divorced

Current Legal Involvement such as Probation, Parole, DCFS, Restraining Order, Drug Court, Family Court?

Are you participating in or about to enter a Medication Assisted Treatment program?

Medication(s)?

Have you ever lived in any type of sober housing?

Name and address of house:Dates of residenceReason for leavingName, address, and phone number of your last landlord:

Have you ever been convicted of arson, sexual offenses, or any other crime?

If yes, please explain the crime(s) and dates

Do you have a current legal status?

By signing this document, you attest that all information you have provided is accurate and that if it is disclosed that you have provided any information dishonestly, your application will not be accepted.

Please enable JavaScript in your browser to complete this form.1234

Name

FirstMiddleLast

Date of BirthSocial Security Number

Are you currently homeless / without a permanent place to live?

Current Address

Address Line 1CityState / Province / RegionPostal CodeCountry

Telephone numbers:Email

Do you have transportation?

Do you currently participate in self-help

Name of program (s)How many meetings do attend per week?Name Of Meetings

Name

FirstLast

What is your marital status

Single
Married
Separated
Divorced

Current Legal Involvement such as Probation, Parole, DCFS, Restraining Order, Drug Court, Family Court?

Are you participating in or about to enter a Medication Assisted Treatment program?

Medication(s)?

Have you ever lived in any type of sober housing?

Name and address of house:Dates of residenceReason for leavingName, address, and phone number of your last landlord:

Have you ever been convicted of arson, sexual offenses, or any other crime?

If yes, please explain the crime(s) and dates

Do you have a current legal status?

Get in touch

Contact us today.

Have questions or need assistance? Send us a message or give us a call! Our dedicated team is here to help you with any inquiries or concerns you may have.

318-224-0837
216 E Georgia Ave, Ruston, LA
recoveringgracefullyllc@gmail.com