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

YYYY

Name

First Name

Last Name

Phone (can currently be contacted)

(###)

###

####

Are you able to do household chores?

Are you physically able and willing to keep up with the chores and rules that are required to live in the homes?

Rehab location you are currently in and your counselor contact information.

Please give full name, rehab name, phone number with extension and email address.

Have you ever been to a treatment facility for addiction?

Date of last drink:

YYYY

Date of last drug use:

YYYY

List the drugs you have used addictively:

Have you ever lived in sober home?

If yes, provide the name and location of the house:

I left transitional housing for the following reason:

Voluntarily

Relapse

Other

I owe money to the house I left:

If accepted, how do you plan to pay for Valentine sober housing? Please elaborate:

How many AA/NA meetings do you attend each week?

Are you currently taking prescription drugs?

If "yes", list the drugs and reason for prescription:

House Interest

When would you like to move in?

YYYY

Email Address

Date of Birth

YYYY

Marital Status

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Message

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.

I Agree

Emergency Contact Name and Phone Number

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.

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