Section 1: Contact Information *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone

(###)

###

####

Preferred Method of Contact?

Phone

Text

Email

Preferred Intake Date

MM

DD

YYYY

Section 2: Current Recovery Status *

Have you completed a minimum of 30 days in a residential treatment program?

Yes

No

Are you currently enrolled in an outpatient program? *

Yes, in-person

Yes, virtual

Not yet enrolled

Section 3: Commitment to Recovery *

The Haven at Chico is more than housing—it’s a healing community. Residents are expected to remain engaged in their recovery, contribute to household responsibilities, and show up for themselves and others. Applicant, please read and check each box to confirm your understanding:

I am committed to maintaining my sobriety and working my recovery program.

I agree to attend all required weekly house meetings and community check-ins.

I will participate in household chores and maintain shared spaces respectfully.

I am open to communication and accountability as part of my growth.

I understand that The Haven at Chico is a supportive living environment, not a treatment program.

I understand that I will provide my own food, toiletries, etc.

I understand that upon admission, I will be signing a room and board contract.

Section 4: Communication & Verification Agreement *

To ensure safety and accountability, The Haven at Chico maintains open communication with each resident’s outpatient provider. This helps support your continued progress and allows for timely coordination if additional support is needed. By signing below, you agree to allow The Haven at Chico staff or house manager to communicate with your outpatient counselor, case manager, or treatment team to confirm attendance and ongoing participation. Your typed name serves as your digital signature. *A hard copy will be signed upon admission.

First Name

Last Name

Today's Date *

MM

DD

YYYY

Section 5: Budget & Availability *

Monthly Budget for Housing: Which is Your Preference?

$1,200 (Private Room) (If available)

$1,000 (Shared Room)

Other