OUR FATHERS MEN’S RECOVERY HOUSE

Housing Intake

Our Fathers is The Healing Hxouse’s first recovery home—a dedicated men’s recovery residence created specifically for fathers in recovery. Complete this confidential pre-screening form so we can understand your housing needs, recovery journey, available resources, and the support that may help you succeed.

Please do not include medical records, Social Security numbers, banking information, or other sensitive documents. This form is not monitored for emergencies. Call 911 for immediate danger or 988 for crisis support.

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Applicant & Contact Information

Full name

Email address

Phone number

Best time and safest way to contact you

I am completing this intake for

1. Housing Preference & Affordability

What type of room are you interested in?

Based on the prices above, are you currently able to afford housing at The Healing Hxouse?

Please don’t let your current financial situation stop you from completing this form. Your answer does not automatically disqualify you. We ask so we can understand your housing needs, available resources, and whether additional funding or support may need to be explored.

Do you currently have a housing voucher, rental assistance, or another source of housing funding?

If yes, what type?

Please provide the name of the voucher, agency, program, or funder

2. Recovery & Sobriety

Our Fathers is a structured, substance-free recovery residence. Applicants must have at least 72 hours clean and sober before admission OR be coming directly from an approved detox or treatment setting. A drug/alcohol screening is required upon entry.

How much continuous clean/sober time do you currently have?

Are you coming directly from a detox, inpatient treatment program, residential treatment facility, hospital, or other recovery program?

If yes, name of facility/program

If yes, expected discharge date (MM/DD/YYYY)

Are you willing to complete a drug/alcohol screening upon admission?

Prescribed medications taken as directed are not considered illicit drug use. This includes medications for opioid use disorder.

3. What Support Would Help You?

Select every type of support that may help you:

Recovery coaching

Peer recovery support

Substance-use treatment referral

Mental-health/community resource referral

Housing or voucher navigation

Employment/workforce support

Transportation assistance

Benefits/resource navigation

Court/probation/reentry support

Family reunification/parenting support

Identification/documents

Other support

Is there anything else you would like us to know about the support you need? (Optional)

4. Children & Family Reunification

Children are not permitted to be at the residence without appropriate supervision and approval under house policy.

Are you a father with a child or children?

Would you be interested in discussing supervised visits with your child/children at the residence when appropriate and approved?

5. Court, Probation & Legal Obligations

Do you currently have any court, probation, parole, DOC, drug-court, family-court, or other legal obligations that could affect your housing or schedule?

If yes, briefly describe anything we should know to determine whether the residence can support your requirements

Are there any current court orders, geographic restrictions, no-contact orders, supervision requirements, or residence restrictions that could affect your ability to live at this location?

6. Criminal-History Screening

Having a criminal record does not automatically disqualify you from housing at Our Fathers. Criminal-history information is reviewed individually and in accordance with applicable law.

Do you currently have criminal-legal circumstances or restrictions that you believe could affect placement in a shared recovery residence?

Are you currently required to register as a sex offender?

Our Fathers is not able to accept applicants who are currently required to register as sex offenders.

7. Privacy Statement

YOUR INFORMATION IS PRIVATE

The information you provide through this intake form is used to evaluate housing eligibility, understand your needs, and determine how The Healing Hxouse may be able to support you. We do not sell your information or share your personal intake information outside The Healing Hxouse without your permission, except when required by law or when necessary to address an immediate health or safety concern.

We understand that recovery, legal history, housing instability, and family circumstances are deeply personal. Please share only what you are comfortable providing during this initial intake. Additional information can be discussed privately with our team.

8. Acknowledgment Before Submit

I understand that:

I am applying to a structured, substance-free recovery residence.

I must have at least 72 hours clean and sober before admission unless I am entering directly from an approved detox/treatment setting.

A drug/alcohol screening is required upon entry.

Completing this intake does not guarantee admission.

Room availability and financial arrangements must be confirmed before move-in.

House rules and the resident agreement will be reviewed before admission.

I understand that Our Fathers serves fathers in recovery.