Housing - Jefferson County LEAD Program

Name

Age

Current Address or Facility Name

City, State, Zip

Phone Number

Email

Are you an alcoholic?

Yes
No

Date of last Drink

Are you addicted to drugs?

Yes
No

Date of last drug use?

List drugs you have used addictively

Do you take prescription drugs?

Yes
No

List any prescription drugs you use.

Have you ever been to treatment for alcoholism and/or addiction?

Yes
No

IF Yes, When/Where?

Do you attend AA/NA Meetings?

Yes
No

Are you working?

Yes
No

IF Yes, Who is your employer?

Do you have any non-job related income?

Yes
No

IF Yes, What is the income?

What is your estimated monthly income?

Marital Status

Requested move in date?

Why is the move in date in the future if not immediately?

Have you ever lived in a recovery house before?

Yes
No

If Yes, Describe.

Do future Drink

Why did you leave the previous recovery house?

Relapse
Voluntarily

Resident Acknowledgment Statement.

No, I do not agree
Yes, I agree.

I understand that the Recovery House I am applying to operates in accordance with the principles outlined in §2036 of the Federal Anti-Drug Abuse Act of 1988 (P.L. 100-690, as amended). As a condition of residency, I acknowledge and agree to the following: All residents are strictly prohibited from using alcohol or illegal drugs. Any resident who violates this rule will be subject to immediate discharge from the house. All household expenses, including rent and utilities, are to be shared equally among residents. House operations and decisions—including matters of admission and discharge—are managed through a democratic, group-based process. I understand that by agreeing to these terms, the recovery house may operate differently from traditional landlord-tenant arrangements, and certain legal protections may not apply in the same way. I have read and understand all information included in this application, have answered all questions truthfully, and am committed to pursuing recovery in a safe, supportive, and substance-free environment.

Use this space for additional relevant information.

Residential Application Form

Victory Villa will provide a safe, supportive, and structured environment for men in recovery. Conveniently located within walking distance of key services and the local bus line, the house is ideally situated to support residents as they work toward stability and independence.