Journey House Intake Application

Please read the Participant Agreement first, and then fill out the application below.

Applications may only be filled out online. Mailed or faxed applications will not be eligible for review.

 

What is your full legal name? *
What is your full legal name?
Which house are you applying to? *
Current housing status *
Be as detailed as possible, and explain your current location / living situation.
Sex *
Date of Birth *
Date of Birth
By checking this box, I acknowledge that I have read and agree to abide by the Participant Agreement *
located at journeyhousemaine.com/contract
4-5 sentences
Substance of Choice *
Be as detailed as possible
Are you willing to attend AA, NA, SMART Recovery, counseling, church, etc. 4x / week? *
Last or Current Address *
Last or Current Address
$
Type of income *
How will you occupy your time at Journey House? *
Your application will not be considered unless you have the funds to move in or you have made every effort to obtain the funds. If you do not have the funds, then here you must detail specifically which sources (churches, caseworkers, the courts, friends, family, etc.) you have discussed payment with, what they have said, and how much they are able to help pay. Scholarships are very limited, and you will not be considered for one if you submit a short or otherwise inadequate answer.
You MUST provide two of these, preferably three. Do not list any Journey House staff and do not list family
If yes, please list the charge(s) and the conviction dates. Criminal history will not necessarily disqualify you.
Drug Court, Probation, Parole, Pretrial, etc. If so, please provide department and contact info:
Name, relationship to you, and phone number
Your phone number *
Your phone number
If law enforcement, treatment, healthcare, or other service provider, please explain: