RESERVE A BED - Florex Recovery Homes

Welcome to Florex Recovery Homes. Please complete the application form to be considered for admission.

Who is completing this form?

I am applying for myself

I am referring someone else

I am helping someone complete this form

Referring Organization

Referral Contact Information For agencies, case managers, treatment providers, or anyone completing this form on behalf of someone else.

Referral or Helper First Name

Referral or Helper Last Name

Title

Department

Phone/Mobile

Date of Referral

Applicant Information

Applicant First Name

Applicant Last Name

Applicant Date of Birth

Phone/Mobile

I agree to receive text messages from Florex Recovery Homes regarding this application or referral. Message and data rates may apply. Reply STOP to opt out.

SMS is not a secure, encrypted communication method. Carriers may store copies of these messages. Message frequency varies. Msg & data rates may apply. Text STOP to cancel.

I agree to receive email communication from Florex Recovery Homes.

Most Recent Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Veteran Status

Yes

Prefer not to answer

Gender for housing placement

Man

Woman

Prefer to discuss by phone

Are you 18 or older?

Yes

Preferred Contact Method

Current Housing Status — check all that apply

Homeless

Emergency Shelter

Treatment Program

Recovery Residence

Primary Reason for Referral

Best Time to Contact

Preferred Move-In Timeline

Immediately

Within 1–7 days

Within 2–4 weeks

Just gathering information

Referral Source

Current Housing Status

Living with Family or Friends

Hotel/Motel

Rental Housing

Other

Primary Reason for Referral (Select all that apply)

Recovery Housing

Reentry Support

Veteran Housing Support

Stable Transitional Housing

Independent Living Prep

Other

Current Recovery Status

Actively in Recovery

Completing Treatment

Recently Discharged

Returning from Incarceration

Seeking Structured Housing

Other

Income / Employment

Current Source of Income

Full-Time Employment

Part-Time Employment

VA Benefits

SSDI / SSI

Retirement

Family Support

None Currently

Other

If employed, what is your employer name?

Support Team

Case Manager First Name

Case Manager Last Name

Case Manager Phone/Mobile

Probation Officer Name, if applicable

Probation Officer Name

Probation Officer Last Name

Probation Officer Phone/Mobile

Treatment Provider Name

Treatment Provider Phone

Eligibility Screening

Please confirm the following:

Applicant is 18 years of age or older.

Applicant is willing to live in a drug and alcohol-free environment.

Applicant is capable of independent living in a shared housing environment.

Applicant is willing to follow community standards and house rules.

Applicant is committed to recovery, stability, employment, education, treatment, or approved life goals.

Additional Comments

share any additional information that may help us understand the applicant’s housing needs.

Consent & Acknowledgment

I consent to the followings:

I confirm that the information provided is accurate to the best of my knowledge.

I understand that submitting this form does not guarantee acceptance or placement.

I consent to be contacted by Florex Recovery Homes regarding this application or referral.

I understand this form is not for emergencies. If I am in immediate danger, I should call 911 or local emergency services.

Please review your information before submitting. Use the Previous button if you need to make changes.

Who is completing this form?

Referring Organization

Applicant Information

Primary Reason for Referral

Current Housing Status

Current Recovery Status

Income / Employment

Support Team

Probation Officer Name, if applicable

Eligibility Screening

Additional Comments

Consent & Acknowledgment

This Application Is For

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