CALL (603) 339-4246

SUBMIT APPLICATION…

_____________________

COMPLETE APPLICATION FORM BELOW AND SUBMIT FORM ELECTRONICALLY VIA “SUBMIT” BUTTON BELOW
$450 REQUIRED FOR INITIAL PAYMENT (Due on move in date – covers first week and move in fee)
$225 WEEKLY FEE

______________________________________________________________________________

First and Last Name:

What Is Your Age?

Date:

Email:

Phone No:

Who Is Involved With Your Recovery?

Do You Have Any Health Problems?

What Is Your Substance Of Choice?

Clean/Sobriety Date?

List Prescription Medications: (if not on any meds, please note that)

Have You Ever Been Charged With Arson? Have You Ever Been Charged With Arson? Yes No

Have you ever been charged or convicted of a sexual offense? Have you ever been charged or convicted of a sexual offense? Yes No

Do You Have Experience With Sober Living? Do You Have Experience With Sober Living? Yes No

What Do You Do For Work?

Do You Have A License? Do You Have A License? Yes No

Do You Have A Vehicle? Do You Have A Vehicle? Yes No

Will You Need Funding? Will You Need Funding? Yes No

What Do You Hope To Gain At Saint Christophers?

Address:
527-529 Lake Ave
Manchester, NH 03103

Phone:
1-603-339-4246

Email: