Membership Application

If you are interested in being considered for membership in one of the Valentine Houses, please complete the application below, then click submit. A representative will contact you once your application has been received.

YOU MUST:

  • Have job/income
  • Be committed to living a sober lifestyle
  • Abide by house rules

VALENTINE HOUSE: 

  • Provides a safe environment
  • Provides support from living with other recovering addicts
  • Increases resident's odds of staying sober
  • Encourages structure and living a purposeful life
Date *
Date
Name *
Name
Phone (can currently be contacted) *
Phone (can currently be contacted)
Are you physically able and willing to keep up with the chores and rules that are required to live in the homes?
Date of last drink:
Date of last drink:
Date of last drug use:
Date of last drug use:
I left transitional housing for the following reason: *
When would you like to move in? *
When would you like to move in?
Date of Birth *
Date of Birth
Phone *
Phone
Address
Address
Emergency Contact
TERMS OF AGREEMENT *
I realize that The Valentine House to which I am applying for residency is a private facility whose regulations differ from the normal due process afforded by some local landlord-tenant laws. House membership requires the following: (A) all residents are prohibited from using any alcohol or illegal drugs, (B) expulsion of any resident who violates such prohibition, (C) all residents are required to pay the weekly membership fee and an equal share of household supplies, and (D) utilization of democratic decision-making within the group including inclusion in and expulsion from the group. I have read all of the material on this application form including the limitations set forth. I have also answered each question honestly and want to achieve comfortable recovery from alcoholism and/or drug addiction without relapse.

Please include rehab name, counselors name and phone number with extension number in the message area.