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  • Treatment History

  • Emergency Contact Information

  • Current Medications:

  • Who will be responsible for paying your residential fees and living expenses if you are accepted to Shoreline Recovery?
  • I realize that the Recovery House to which I am applying for residency has been established in compliance with the conditions of §2036 of the Federal Anti-Drug Abuse Act of 1988, P.L. 100-690, as amended, requires the house residents to remain abstinent from drugs and alcohol. I realize that I can be expelled from the house that I become a member of, if for some reason I return to using drugs and alcohol and/or if my behavior is such that it compromises the moral integrity of the house. I also realize that at such time that I am expelled; I will have 30 minutes to remove my personal belongings from the house or make arrangements to come back for them. I also realize that if I am hospitalized and/or expelled, my emergency contact will be notified.

    I have completed this application and have answered questions honestly and to the best of my ability. I agree that if I am accepted into Shoreline Recovery. I accept the terms of this application and the terms of the rules and policies of Shoreline Recovery, and I have made a commitment to achieve sobriety and recovery from alcoholism and/or drug addiction without relapse. In accepting these terms, the applicant understands that §2036 conditions are different than the normal due process afforded by some local landlord-tenant laws.