men’s Online Application Please review our Community Standards before submitting application. Community Standards Name * First Name Last Name Date of Birth * MM DD YYYY Age * Gender Phone * (###) ### #### Email * How did you hear about Straight Street? * Requested move in date * MM DD YYYY How long of a commitment are you interested in? * 6 months 12 months Do you have a job? * Yes No Are you able to pay the $425 intake fee? * Yes No (A non-refundable administrative fee of $300 plus your first week program fee of $125 is required before being accepted to the program. Grants and funding may be available for certain individuals depending on eligibility after first $425 is paid.) Are you a registered sex offender? * Yes No Are you on parole, probation, waiting to be sentenced, awaiting a hearing/trial? * Yes No If yes, please explain Parole Officer's Name First Name Last Name Parole Officer's Phone # (###) ### #### Have you had any mental health diagnosis in your lifetime? Yes No If yes, what was the diagnosis? Are you on any medications? * Yes No If yes, what are the medications you are currently taking? Why are you applying to Straight Street? * Emergency Contact's Name * First Name Last Name Emergency Contact's Phone Number * (###) ### #### Do you understand and agree to the Community Standards? * Yes No Do you understand that you are required to attend one church service and two recovery classes or twelve step groups each week, submit to random/ regular urine analysis and breathalyzer tests? * Yes No Please type your name below as an "electronic signature" * Thank you for your application! Please allow 3-5 business days for a call back from our intake coordinators.
