Start your recovery today

This confidential intake takes about 5 minutes. It helps us understand your situation and match you with the right home. There are no wrong answers — just be honest, and we'll take it from there.

All fields are required to continue, except where marked optional.

Personal information

First name

Last name

Date of birth

Phone number

Email address

Preferred home

Target move-in date

How did you hear about us?

Please complete all fields above to continue.

Step 1 of 4

Recovery background

Current sobriety date

Coming from

Prior treatment episodes

Currently in IOP/PHP?

Do you have a sponsor or recovery support person?

Brief description of your recovery goals

Please complete all fields above to continue.

Step 2 of 4

Practical & behavioral screening

Employment / income status

Able to pay weekly rent?

Any history of violence or aggressive behavior in a treatment setting?

Current legal issues or pending charges?

Any mental health diagnoses we should be aware of?

Emergency contact name & phone

Anything else we should know? (optional)

Please complete all required fields above to continue.

Step 3 of 4

Review & submit

By submitting, you acknowledge that you agree to follow all house rules and policies of Mind, Body & Soul Recovery, including random drug testing, curfew, and chore requirements. Your information is kept confidential.

Step 4 of 4

Reviewing your application…

Start your recovery today

Personal information

Recovery background

Practical & behavioral screening

Review & submit

What our team will review

Questions we may ask you

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