Heart Rock recovery center could be the new beginning you seek

You’ve explored our programming, you’ve visited the premises via our virtual tour and you’ve confirmed you qualify for the long-term sober living program at Heart Rock recovery center. The only thing left to do, is apply.

Apply Online

Fill out our secure, confidential online form below.

Form needs to be completed in its entirety.

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Previous Address *

Address Line 1

Address Line 2

City

State

Zip Code

Social Security # *

Date of Birth *

Phone *

Gender *

Pronouns *

she/her/hers
they/them/theirs
other

Ethnic Background *

Black
Caucasian
Hispanic
Other

Valid drivers license *

Vehicle *

Family size *

Number of children *

Are you pregnant? *

Military Service *

Were you referred? *

Emergency contact

Name *

Relationship *

Phone *

Name *

Relationship *

Phone *

Substance Use Information

Sobriety date *

Length of longest sobriety *

Other drugs used *

Frequency of use? *

How do you use? *

Have you ever used or shared a needle? *

Age of first use? *

Substance Abuse/Mental Health Treatment

Have you ever been diagnosed with a mental health disorder? *

Were you actively using at time of diagnosis? *

Have you ever had issues with an eating disorder? *

Are you in a facility? *

Treatment history

Date

Program Name & Type

Length

Outcome of Treatment

Medical Information

Do you have medical insurance? *

Have you received the COVID-19 vaccine? *

Have you received the COVID-19 booster? *

Have you tested positive for COVID-19? *

Date of your last physical examination *

Physician's Name/Clinic *

Are you currently under a physician's care? *

Do you have any medical/physical issues that need to be addressed? *

List all medications, include over the counter and prescription.

Name of medication

Dosage/frequency

Route

Reason for medication

Name of medication 1

Dosage/frequency 1

Route 1

Reason for medication 1

Name of medication 2

Dosage/frequency 2

Route 2

Reason for medication 2

Name of medication 3

Dosage/frequency 3

Route 3

Reason for medication 3

Name of medication 4

Dosage/frequency 4

Route 4

Reason for medication 4

Have you been diagnosed with a mental health disorder? *

Are you currently seeing a therapist? *

Have you ever had issues with an eating disorder? *

Do you currently have suicidal thoughts or feelings?

Domestic Violence

Have you ever been in a domestic violence situation? *

Are you currently fleeing a domestic violence situation? *

Protective order? *

Criminal History

Do you have any past criminal charges? *

Are you a registered sex offender? *

Do you have any current charges? *

Pending Charges *

Currently on Parole or Probation? *

Income/Employment History

Currently employed? *

Collecting unemployment? *

Collecting disability? *

SNAP benefits *

TANF benefits *

Most recent work experience

From & To *

Company *

Position *

Why did you leave? *

Apply Online

Fill out our secure, confidential online form by clicking the button below.

Fill Out Online Form

Apply Via Email

Fill out the PDF form linked below and email it to contact@heartrockrecovery.org

Download PDF

Heart Rock recovery center could be the new beginning you seek

Apply Online

Form needs to be completed in its entirety.

Emergency contact

Substance Use Information

Substance Abuse/Mental Health Treatment

Medical Information

List all medications, include over the counter and prescription.

Domestic Violence

Criminal History

Income/Employment History

Most recent work experience

Apply Online

Apply Via Email

Recovery
with heart

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Heart Rock recovery center could be the new beginning you seek

Apply Online

Form needs to be completed in its entirety.

Emergency contact

Substance Use Information

Substance Abuse/Mental Health Treatment

Medical Information

List all medications, include over the counter and prescription.

Domestic Violence

Criminal History

Income/Employment History

Most recent work experience

Apply Online

Apply Via Email

Recovery with heart

Share this page

Recovery
with heart