Apply for Residency

Name

Date of Birth

Alternative Phone

Address

Are you currently in a residential drug and alcohol treatment facility?

If yes, where?

If yes, when is your completion/discharge date?

Name of Counselor

Phone Number Where You Can Be Reached

Marital Status

How will you pay your admission and monthly rental fees?

Will you be attending an Intensive Outpatient Program (IOP)?

If yes, where?

Drug(s) of Choice

Date of last use

Medical and/or Mental Health Diagnosis

Medications you are currently prescribed (Applicants will be declined if using any controlled substance including Methadone or Suboxone.)

Talbot House is a 501(c)3 public charity.

sober living for women