Apply for Residency | Clearwater Recovery

SECTION 1: Personal Information

First name

Last name

Date of Birth

Month

Day

Year

Phone

Email Address

Current Address (or Facility Name)

Emergency Contact Name & Phone

Preferred Method of Contact

Phone

Text

Email

SECTION 2: Background Information

Are you currently incarcerated or on probation/parole?

Yes

No

If yes, please list supervising officer and contact information:

Expected Release Date (if applicable):

Do you have any pending charges or court dates?

Yes

No

If yes, please explain:

Have you participated in a recovery program before?

Yes

No

If yes, which one(s) and when?

Date of last use (estimate):

Have you ever experienced severe withdrawal?

Yes

No

Explain any detox history or current concerns:

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

Yes

No

SECTION 3: Health & Support Needs

Do you have any physical or mental health diagnoses?

Yes

No

If yes, please list:

Do you currently take any medications?

Yes

No

If yes, list them below or bring a written list to intake:

Do you need help obtaining an ID, Social Security card or birth certificate?

Yes

No

Do you currently have health insurance?

Yes

No

If yes, what kind?

Medicaid

Medicare

Private

Other

SECTION 4: Faith & Motivation

This is a faith-based recovery home. Are you open to participating in Christian-based recovery services, including Bible Study, prayer, and spiritual mentorship?

Yes, I'm open to it

I'm unsure, but willing to learn

No

Do you have a personal relationship with God or interest in building one?

Yes

No

What role has faith (if any) played in your recovery journey so far?

Why do you want to come to Clearwater Recovery?

SECTION 5: Readiness & Availability

Are you currently homeless or in need of immediate housing?

Yes

No

Are you willing to participate in daily work, group sessions, and recovery activities as part of the program?

Yes

No

Are you able to commit to at least 90 days in this program?

Yes

No

If no, please explain:

When would you be ready to enter the program?

Immediately

Within 1 Week

Within 30 Days

SECTION 6: Optional Uploads

Upload a copy of your ID or DOC release paperwork (if available):

Upload a letter of recommendation, if you have one:

SECTION 7: Final Agreement

I understand that Clearwater Recovery is a faith-based, structured recovery support home. By submitting this application, I am expressing a willingness to engage in personal growth, faith-based mentoring, and a work-based recovery program.

I agree to the above and would like to be considered for admission

Clearwater Recovery Application for Admission