Housing Application

Complete this secure application to be considered for our sober living housing program. All information is confidential and HIPAA compliant.

Important Information

This application is for current and former clients of Serenity Behavioral Health Services. Housing placement is subject to availability and clinical assessment. Please complete all sections thoroughly.

Personal Information

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Current Address

Treatment History with Serenity BHS

Current Client Status *

Primary Counselor/Case Manager

Services Currently Receiving (check all that apply)

Housing Preferences

Preferred Housing Type *

Desired Move-in Date *

Special Accommodations or Needs

Financial Information

Employment Status *

Monthly Income (approximate)

How will you pay for housing costs?

Emergency Contact

Contact Name *

Relationship *

Phone Number *

Email Address

Additional Information

Why are you interested in our housing program?

Additional comments or information

Agreement and Consent

I understand that this application does not guarantee housing placement and that all placements are subject to availability and clinical assessment. I agree to participate in required treatment services and follow all housing program rules and guidelines.

I consent to Serenity BHS sharing relevant treatment information with housing program staff for the purpose of coordinating my care and ensuring program compliance.

Questions about the application process? Call us at (567) 429-1000