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Residence Information
Level of Support
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Residence Address
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Manager Name
*
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Type of Structure
*
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Number of Units
*
Number of Bedrooms
*
Number of Bathrooms
*
Number of Beds
*
Property Ownership
*
Owned by member
Leased from a third party
Leased from a person/entity related to member
Other
Other
Do you welcome persons on a Medication Assisted Treatment protocol into your system?
Yes
No
Priority Population
*
Check all that apply
Women
Men
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Women with Children
LGBT
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Pregnant Women
Recovery Path
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12 Step
Faith-based
Celebrate Recovery
SMART
Is your residence abstinence based?
*
Yes
No
Is food included in fees?
*
Yes
No
Do you manage resident funds?
*
Yes
No
Date Established
*
Rent or Program Fees
Billing Frequency
*
Weekly
Monthly
Both
Shared Room Amount
Private Room Amount
Administrative Fees
Deposit Amount
First and Last Amount
Pro-rated Amount
Website Listing Information
Who should be listed as the primary contact on the FARR public facing website?
*
Residence Profile
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Website
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Logo
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