Apply for Transitonal Housing | Restorative Roots Wi

Section 1: Applicant Information

First name

Last name

Home County

Section 2: Clinical Context

Are you currently in treatment, recently completing treatment, or coming from another recovery residence? If yes, Where and How Long have you been in treatment?

Expected Discharge Date

Counselor/Discharge Coordinator Contact Information

Section 3: Funding Eligibility

Check any that apply:

I am a permanent resident of Luzerne or Wyoming County, PA and have a diagnosis of Opioid Use Disorder.

I am a permanent resident of Luzerne or Wyoming County, PA and I am stepping down from a higher level of treatment

I am a permanent resident of Lycoming, Northumberland, Snyder, Columbia, Montour, or Union County, PA and am stepping down from a higher level of treatment.

Other/None of the above

Do you have a source of income, employment, benefits, or funding to cover your housing expenses if necessary?

Section 4: Statement of Intent

What are you hoping to gain from living in a sober living environment, and what are your goals for your recovery over the next several months?

2 Personal References (Name, Occupation, Time known, Phone Number)