Admissions

Resident Application

Where healing finds harmony

Women age 18+ • Recovery Housing • Indianapolis, Indiana

Please complete all applicable sections. If a question does not apply, write N/A. This application helps determine whether Harmony Haus is an appropriate recovery-housing fit. It is not a clinical assessment and does not guarantee admission or bed availability.

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1Applicant & Referral Information

Full legal name *

Preferred name

Date of birth *

Phone number *

Email address (optional)

Preferred language

Current address or location

Do you have a government-issued photo ID?

Driver's license or state ID number (optional)

Social Security number *

Required for identity verification. Kept confidential and visible only to authorized Harmony Haus administrators.

How did you hear about Harmony Haus?

Referral organization (if any)

Referral contact name / phone / email

Privacy note: Harmony Haus will not contact treatment providers, case managers, supervision officers, or other third parties regarding protected information without a separate signed authorization when one is required.

2Emergency Contact

Emergency contact name *

Relationship to applicant

Primary phone *

Alternate phone / email

May Harmony Haus contact this person in a genuine emergency?

3Current Housing Situation

Current housing situation

Why are you seeking recovery housing at this time? *

4Recovery History & Current Supports

Provide enough information for housing screening and recovery planning. Detailed clinical records are not required with this application.

Primary substance(s) of concern

Date of last use (if known)

Recovery / sobriety start date (if used by you)

Are you currently engaged in substance-use treatment?

Treatment provider / program (if applicable)

Counselor / clinician / case manager

What recovery supports have been most helpful to you?

Have you lived in recovery housing before? If yes, where, and what helped or made it difficult?

What are your three most important goals for the next 90 days? *

5Medication & MAT Information

MAT-friendly: Prescribed medications, including medications for opioid or alcohol use disorder, are permitted when used as prescribed and handled according to Harmony Haus medication policy. MAT use is not an automatic reason for denial.

Are you currently prescribed medication for opioid or alcohol use disorder (MAT/MOUD)?

Are you able to self-administer and manage your medications as required?

Current medications

List each medication with dose, frequency, and prescriber or pharmacy.

6Immediate Health, Safety & Accommodation Screening

These questions determine whether recovery housing is an appropriate level of care today and whether reasonable accommodations should be discussed. A health condition, disability, or request for accommodation is not automatically disqualifying.

Do you have any medication allergies or serious adverse reactions we should know about for emergency safety?

If yes, list the medication / allergy and the reaction

Are you currently experiencing significant withdrawal symptoms, or do you need detoxification / medical stabilization before entering recovery housing?

Are you currently experiencing an urgent medical or behavioral-health crisis that requires immediate professional care?

Are you able to independently complete basic daily living tasks needed in a shared residence, with or without reasonable accommodation?

Do you have mobility, accessibility, communication, dietary, or other accommodation needs?

If yes, describe what support or accommodation would help you participate safely in the residence

Do you use or need a service animal or assistance animal?

Do you have a primary-care or behavioral-health provider you want listed for continuity of care?

Provider / organization (optional)

Provider phone (optional)

If you are in immediate danger or have a medical emergency, call 911. For urgent mental-health or substance-use crisis support in the U.S., call or text 988.

7Legal / Court / Community Supervision

This information is collected only to identify requirements that may affect residency, curfew, appointments, safety, or coordination. Justice involvement by itself is not treated as an automatic housing decision on this form.

Are you currently under probation, parole, community corrections, problem-solving court, work release, or another supervision requirement? *

Supervising agency / program

Officer / case manager name

Phone / email

Are there court orders, geographic restrictions, protective orders, or other legal requirements that could affect your ability to live in shared housing?

If yes, explain only what Harmony Haus needs to know to determine housing compatibility

Upcoming required court, treatment, probation/parole, or other appointments that may affect your schedule

8Daily Living, Employment & Transportation

Preferred room type

Room preference is not guaranteed and is based on eligibility and availability.

Preferred move-in date *

Current employment / education status *

Employer / school / program (if applicable)

Typical schedule

Approximate monthly income / benefit source (optional)

How do you expect housing fees to be paid?

Do you have reliable transportation for work, treatment, meetings, and appointments?

Do you smoke or vape?

Smoking and vaping are only allowed in designated outdoor areas, per house policy.

10Strengths, Needs & Recovery Goals

What strengths will you bring to the Harmony Haus community?

What is your biggest concern about entering recovery housing?

What support would help you be successful here?

9Recovery Residence Fit & House Expectations

Harmony Haus is recovery housing — not detoxification, inpatient treatment, or a clinical program. Residents are expected to participate in a structured, substance-free shared living environment and remain engaged in their individual recovery plan.

I understand and am willing to: *

Are you willing to live cooperatively in a shared household with other women in recovery? *

Do you have any concern about following the expectations above?

If yes, please explain so we can discuss whether an accommodation, support plan, or another placement would be a better fit

11Applicant Certification & Consent

I certify that the information I provided on this application is true and complete to the best of my knowledge.I understand that submitting this application does not guarantee admission, a specific room type, or bed availability.I understand Harmony Haus provides recovery housing and does not provide detoxification, medical treatment, psychiatric treatment, or other clinical services.I understand Harmony Haus may need additional information before making an admission decision, and protected information will be obtained or shared only with appropriate authorization or as otherwise permitted by law.I understand that, if accepted, I will review and sign separate resident rights, housing, financial, medication, drug-testing, confidentiality/ROI, safety, and house-policy documents before or at admission.I understand that reasonable accommodation requests may be discussed as part of the application/admission process.

Applicant signature — type your full name *

Date

12Supporting Documents Checklist

Check only what applies to you and to your referral or payment arrangement. You do not need to upload anything now — our team will request documents if they are needed.

Photo ID / identification availableEmergency contact informationCurrent medication list (if applicable)MAT verification (if needed under house policy)Referral information (if applicable)Treatment / case-management contact (if applicable)Court / supervision requirements (if applicable)Third-party payer authorization (if applicable)Accommodation information requested by applicant

Your application is sent over an encrypted connection and stored in a private database that only authorized Harmony Haus administrators can open.