Apply | Pre-Screening Application

Please read before completing this form: This is a pre-screening application only. It does not guarantee housing. The Licensee Agreement and House Rules will be reviewed and signed in person before move-in.

Substance Use History

Note: All residents are subject to random drug and alcohol testing at any time.

Do you have a history of substance use?*

Recovery Status*

Attending support meetings?*

Program / Meeting Name

Meeting Frequency

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

Legal & Criminal History

Note: Having a criminal history does not automatically disqualify anyone from housing here.

Have you ever been convicted of a crime?*

Prison / Inmate ID Number

Length of Incarceration

Facility Name

Facility State

Release Date

Release Type

Active Legal Obligations (check all that apply)

Supervising Officer Name

Officer Phone

Agency / Department

Reporting Frequency

Acknowledgment & Signature

Please read and check each statement. All are required. *

Everything written in this form is true, complete, and accurate to the best of my knowledge.I understand that providing false or misleading information is grounds for immediate denial or removal.I give Healing Haven Home LLC permission to verify all information provided.I understand all residents must maintain employment or verified income, follow House Rules, and participate in drug/alcohol testing.I understand Healing Haven Home LLC may share information with criminal justice personnel if required by law.I understand this is a Licensee Agreement application, not a lease, and occupancy may be revoked for rule violations.

Applicant Full Name*

Date*

Electronic Signature — type your full name to sign*

By typing your name above, you agree this constitutes your electronic signature.

A legal representative or guardian is also signing this application

Pre-Screening Application

About You

Emergency Contact

Employment & Income

Substance Use History

Medical Information(Optional)

Legal & Criminal History

How Did You Hear About Us

Acknowledgment & Signature