Initiation

Community Standards

Have you reviewed the Reflections House Guidelines?

Yes, I accept the terms. Read Guidelines First

Step 01

Personal Identity

Full Legal Name

Email Address

Date of Birth

Social Security Number

Primary Phone

Gender Identity

Step 02

Referral

Has anyone referred you to Reflections Recovery Home?

Yes No

Step 03

Employment

Are you capable of maintaining full-time employment or education?

Yes No

Most Recent Employer

Step 04

Emergency Contact

Contact Name

Relationship

Contact Phone

Step 05

Clinical History

Have you successfully completed a primary treatment center?

Yes No

Sobriety Date

Step 06

Recovery Support

Do you have a current 12-Step Sponsor?

Yes No

Will you commit to a 90 meetings in 90 days protocol?

Yes No

Step 07

Health & Wellness

Will you comply with our Restricted Medication policy?

Yes No

List Current Medications

Step 08

Legal History

Are you a registered sex offender (RSO)?

Yes No

Describe any pending legal issues

Finalize

Ready to Submit

By clicking submit, you confirm that all information provided is accurate and that you are ready to join the Reflections fellowship.