Tribe Recovery Homes Application
Please answer every question, if it does not apply to you please type "N/A"
Select Your Program
Denver, Colorado
Boulder, Colorado
Sin City, Nevada - (Housing Option Coming Soon)
Choose What You Are Applying For
Inpatient
Housing Program
General Outpatient
Mental Health
DUI
IOP
Unsure
First Name
Middle Name
Last Name
Date Of Birth
Gender
Select an option
Male
Female
Trans
Non-binary
Race
Select an option
American Indian or Alaska native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Hispanic
Ethnicity
Hispanic or Latino or Spanish origin
Non Hispanic or Latino or Spanish origin
Phone Number
Email
Employment: (If none, please type "None")
Position
Are you currently on or planning to apply for any of the following?
SSI
SSID
Disability
None
Do you have health insurance?
Yes
No
Insurance Provider (If you are not insured at this time, please select "No Insurance"
Select an option
Medicaid
Medicare
Private
No Insurance
Are you on any of the following Medically Assisted Treatments (please select all that apply) If you are not on any of the following please select "None"
Methadone
Suboxone
Sublocade
Vivtrol/Naloxone
Anabuse
Other
None
If other please explain
PLEASE NOTE we DO NOT accept any narcotic medications including but not limited to: Benzodiazepine's, Barbiturate's, Narcotic pain medications, Amphetamines, etc.
Legal Situation (If none please select "N/A")
Select an option
Probation
Parol
Pre-trial
Open case
In Custody
N/A
If in custody, who may we contact regarding your application results? please provide Full name, Phone Number and E-mail (If you are not in custody and we can contact you directly, please write "N/A"
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
Tribe Recovery Homes performs a CBI Background Check on all potential applicants. This background check is to protect both current program participants and prospective applicants.
By signing you give permission to Tribe Recovery Homes Inc to run a background check.
This background check does not disqualify you from the program eligibility, nor will the results be disclosed to ANY outside entities.
Date
by typing my name below, I state this is my signature.
Office Use Only Do Not Fill This Section Out
Status
Any Additional Comments
Submit