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To become a house guest

Thank you for your interest in House of Grace!

Apply Today!

We’re looking forward to reviewing your application!
You may choose from the following options:

Mail-in Form: Download, print and write-in your application then mail your completed copy to: HOUSE OF GRACE RECOVERY HOMES, 4448 US HWY 52, Thorntown, IN 46071
E-mail Form: Download, open in Adobe Acrobat Reader, click “Fill in forms fields” icon and complete your application electronically, save file then e-mail your completed copy to: houseofgracerecoveryhomes@gmail.com
Complete the online form below:

Pre-Application Form

Name *

Name

First

First

M.I.

M.I.

Last

Last

Maiden Name

Date of Birth *

Phone *

Email *

Address *

City *

State *

Zip *

Emergency contact name *

Relationship

Phone *

Email

Did you receive a recent medical detox?

Yes

No

If yes, length of stay?

Date of discharge?

If yes, where?

Are you an alcoholic?

Yes

No

If yes, how much do you drink daily?

Date last drank?

Are you an addict?

Yes

No

If yes, drug of choice and how much do you use per day?

Date last used?

Are you or will you be on... Probation?

Yes

No

Parole?

Yes

No

House arrest?

Yes

No

If yes, what county?

Probation/Parole Officer Name:

Phone

Do you have any outstanding warrants?

Yes

No

Do you have a hold in any other county?

Yes

No

If yes, where?

Have you ever been convicted of a violent crime or a sex crime?

Yes

No

If yes, when and where?

Do you take any kind of medications?

Yes

No

If yes, what kind?

Do you have any kind of mental illnesses?

Yes

No

If yes, what kind?

Are you married or in a relationship?

Yes

No

Name of significant other?

Are you approved for Recovery Works?

Yes

No

Will you be responsible for you fees?

Yes

No

If no, how do you plan to pay your fees?

If accepted, when would you plan to arrive for entry into our program?

Attorney’s name:

Phone

If you are human, leave this field blank.

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