Please complete this form (click the icon to download) and MAIL to:
Women’s Recovery House
P.O. Box 1194
Athens, OH 45701
We are very pleased that you are interested in living at Serenity Grove. If some questions do not apply to you, mark them as N/A or leave them blank. We will contact you to let you know when we have received your form. If you are contacted for an interview, you will need to bring a valid photo ID, insurance information, copies of your past assessments, and/or your discharge papers. For questions call: 740-592-1178 or email: firstname.lastname@example.org.
Legal Last Name : First Name: M.I.
Preferred Name(s) Last: First Name: Other names you have used:
Street Address: City:
County: State: Zip:
Date of Birth: Current age: Your home County:
Phone numbers (cell): May we leave a message? yes no
(other #): May we leave a message? yes no
E-mail: May we send you e-mail? yes no
How did you learn about Serenity Grove or who referred you?
What is (are) your main reason(s) for being interested in living at Serenity Grove?
Print Your Name:_________________________________________________________
Your Signature: ___________________________________________Today’s Date:__________________
Please use the other side if you need more room for any answer.
Rev: 5/10/18 syw