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The Potter's House

Applicant Information

* Indicates required field

Name *

First

Last

Date of Birth *

Any prior rehab/halfway house/treatment? YES or NO *

If YES, please describe. *

Drug of choice: *

Current medications you are prescribed: *

Do you have a valid picture ID? *

Do you have a Social Security card? *

Are you currently working? *

Do you have a vehicle? *

Are you willing to take random drug screen and breathalyzers? *

Emergency Contact Information

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Relationship to applicant *

I have read the Potter's House "Contract of Residency" and agree to its terms: *

Yes No

I'm Ready!