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Apply For Residency

Home | Apply For Residency

For a PDF version of the application please click the download button.

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The Lilac House

RESIDENT INFORMATION FORM

Date *

Entry Date

First Name *

Last Name

Date Of Birth

Age *

Phone Number *

Email Address *

Previous Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

NYS ID *YesNo

NYS ID #

Disabled *YesNo

Gender Identity

Ethnicity *HispanicNon Hispanic

Race *

Marital Status *SingleMarriedSeparatedDivorced

Housing Category *HomelessAt Risk Of HomelessnessStable HomeRecently Released From IncarcerationN/A

Education Level *DiplomaCollege DegreeVocational TrainingSome CollegeN/A

Source Of Income *EmploymentSSI/SSDFood StampsDPSS/TANFN/A

Income Frequency *WeeklyBiweeklyMontlyN/A

Are you currently on *ParoleProbationOtherN/A

Parole/Probation Office Location *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

First Name

Last Name

Phone Number

In Case Of Emergency Contact

First Name

Last Name

Relationship *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone

Recovery Information

Do you have a history of alcohol or illegal drug use? *YesNo

How many years did you use drugs and/or alcohol?

List substances you have used within the past 3 years:

Drug of Choice

Clean Date

Name and address of recovery program (if applicable)

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Personal Goals

How did you hear about The Lilac House? *

During my stay at The Lilac House I would like to work on the following *Obtain Social Security CardObtain State ID / Driver’s LicenseReconnect/Reunify with Children/FamilyFind A Recovery SponsorContinue EducationFind A JobLearn A New Skill

Other goals (please describe) *

Save as Draft

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