Evergreen Northwest Recovery Residence

Personal Information

First Name *

Last Name *

Date of Birth *

Age *

Email *

Phone Number *

Current Address *

City *

State / ZIP *

Recovery & Treatment Background

Substance(s) of Concern *

Are you currently engaged in treatment? *

Yes

No

Planning to engage

Treatment Provider / Counselor (if applicable)

Are you taking Medication-Assisted Treatment (MOUD)? *

Yes

No

Planning to start

If taking MOUD, please specify medication(s)

Length of Current Sobriety *

Health & Safety Screening

Note: This is not a medical diagnosis. Answers help us provide appropriate support and accommodations.

Recent alcohol/illicit-drug use or withdrawal risk

History of overdose

Naloxone (Narcan) Training

Yes

No

Willing to receive

Current medications, including MOUD or mental-health medication

Prescriber/Pharmacy (only with your authorization)

Medical, mobility, dietary, sensory, or mental-health accommodation needs

Are you currently experiencing a medical or psychiatric emergency, severe withdrawal, or risk of harming yourself/others? *

Yes - STOP: Please call 911 or 988

No

Daily Living & Participation

Expected Ability to Pay Rent *

Current Benefits/Voucher Status

Employment/School Status *

Transportation Needs

Criminal/Legal Supervision Conditions Relevant to Housing Safety

Housing & Support

Why are you interested in recovery housing? *

Do you have family or peer support? *

Yes

No

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Additional References/Providers We May Contact

Applicant Certifications & Consent

Important: This is recovery housing, not a treatment facility. Recovery housing provides safe, supportive environments where residents help each other maintain recovery.

I understand this is recovery housing, not a treatment facility.

I certify all information provided is accurate and truthful.

I agree to follow the resident agreement and house rules.

I understand that prescribed medications including MOUD are permitted, subject to lawful safety procedures.

I authorize Evergreen Northwest to contact references/providers listed above for housing-related screening.

I understand this is a drug-free, alcohol-free residence and agree to comply with all policies.

I understand that I may be subject to drug screening and agree to random testing.

I am committed to recovery and will participate in house meetings and community activities.

Applicant Signature (or print name) *

Applicant Signature Date *

Screening Decision (Staff Use Only)

⚠️ Staff Section: The following fields are for Evergreen Northwest staff only and will be completed during the screening process. Applicants cannot edit these fields.

Screening Staff Name / Date

Screening Decision

Approved

Waitlist

Denied

Refer to higher level of care

Reason and Objective Criteria

Reasonable Accommodation Considered

Yes

No

Reviewer Name / Date

Additional Information

Please tell us anything else we should know about your recovery journey