Purple Passion Recovery House

Apply for Residency

First Name *

Last Name *

Preferred Location *

West Akron

Cleveland Ohio (Coming soon)

Goodyear Heights (Coming soon)

Date of Birth: *

Age *

Phone *

Email *

To join one of our houses, please agree to the following by checking each box below. *

Sharing a room with another house member

Completing assigned weekly household chores

Following the set curfew

Attending weekly house meetings

Participating in at least three recovery activities per week

Submitting to drug and alcohol testing at any time

Are you presently undergoing treatment?

If yes, please specify the facility or location.

Sobriety Date: *

What steps are you taking toward your recovery? *

Are you covered by any medical insurance plan? *

If yes, please provide the name of your health insurance provider.

Insurance Card Information: *

Please list any prescription medications you are currently taking.

Do you have any current or past legal issues? *

Are you currently on probation, parole, or participating in a drug court program, or do you have any pending charges? If yes, please specify. *

Have you ever been charged with or convicted of a violent crime? If yes, please explain the circumstances. *

Have you ever been charged with or convicted of a sexual offense, or are you currently listed under Megan’s Law? *

Do you plan to attend outpatient treatment services? If yes, please specify the location or facility. *

Do you have the financial means or funding available to move in upon acceptance? *

Do you understand that, upon acceptance, you will be responsible for providing your own bedding (sheets, pillows, blankets, etc.)? *

What’s the best way to reach you? (Should we contact you directly or through a representative?) *

Preferred Move-In Date: *

EMERGENCY CONTACT

CONTACT #1

Name: *

Contact Number: *

Email: *

Connection Category: *

Notes:

Consent: *

CONTACT #2

Name: *

Contact Number: *

Email: *

Connection Category: *

Notes:

Consent: *

Probation or Parole Officer Name: *

Probation or Parole Officer Contact Number: *

Drivers or State Issued ID *

Do you have a car or any motor vehicle? *

If yes, please specify the vehicle’s make and model.

License Plate Number:

Is there anything else you’d like to share with us?

DEMOGRAPHICS

Any demographic information you share is collected only for statistical tracking and will not influence your application’s evaluation.

Contact Our House Manager
By checking this box, I acknowledge that I must reach out to the House Manager after submitting this form. After speaking with the House Manager, we would like to provide you with an overview of the interview process.

During the interview, you will have the opportunity to share your background and discuss the circumstances that led you to seek recovery housing. Current house members will also have an opportunity to ask you questions, and you are encouraged to ask any questions you may have in return. You will be informed of the expectations and requirements for residency, as well as the ways in which residents support and hold one another accountable.

The purpose of the interview is to determine whether you are a suitable fit for the house and its community.

Contact Number:

Email:

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