Structure Home Living
A Safe, Structured Path to Stability and Independence
Submit Placement Inquiry
Complete all sections below. Your information is kept confidential.
This form takes approximately 3–5 minutes to complete.
1. Info
2. Referral
3. Situation
4. Recovery
5. Financial
6. Considerations
7. Submit
Step 1: Basic Information
Full Name
*
Phone Number
*
Email Address
*
Date of Birth
*
Gender
*
Select one
Male
Female
Other
Prefer not to say
Step 2: Referral Information
Are you a referral partner or self-referral?
Select one
Self
Referral Partner
Family/Friend
Other
Organization Name
Referral Contact Name
Referral Contact Phone
Referral Contact Email
Step 3: Current Situation
Current Living Situation
*
Select one
Treatment Center
Detox
Hospital
Homeless
Living with Family/Friends
Currently in sober living
Other
Current City/State
*
Preferred Move-In Timeline
*
Select one
ASAP
Within 1 week
1–2 weeks
Just exploring
Step 4: Recovery & Readiness
Are you currently in recovery?
*
Select one
Yes
No
Are you willing to live in a structured sober living environment?
*
Select one
Yes
No
Are you willing to follow house rules, including curfew, testing, and accountability?
*
Select one
Yes
No
Step 5: Employment & Financial
Are you currently employed?
*
Select one
Yes
No
If not employed, are you actively seeking work?
Select one
Yes
No
Not applicable
Do you have income or financial support?
*
Select one
Yes
No
Step 6: Additional Considerations
Any medical or mental health conditions we should be aware of?
Any current medications?
Any legal requirements, probation, court obligations, or pending cases?
Step 7: Final Information
Is there anything else you would like us to know?
I understand that Structure Home Living is a structured sober living environment and not a licensed treatment program.
*
Back
Next