Motivation comes from within —

and we are here to help you activate it.

Apply for Ben’s House

To apply for recovery housing, please complete the application below. We will contact you using the information provided in your application.

If you have any questions, don't hesitate to get in touch with us via email or phone.

Email

lila@kingdomcollaborative.org

Phone
Main Contact, Lila Bennett: (802) 624-3844

Ben’s House Phone: (802) 766-3012

Contact Information

Name

First Name

Last Name

Phone

(###)

###

####

Please list at least two personal contacts. Include their phone number, email and your connection to them.

Demographic Information

Date of Birth

YYYY

Sex

Gender Identity

History

If you wish not to answer a question below, enter N/A for all required questions. If you choose not to answer you may be asked these questions again during the screening process.

Please describe your substance use history.

Please include drug of choice and years of use.

Do you have any physical health / medical conditions or disabilities?

Are you currently using any prescription medications?

Are you participating in or about to enter any drug replacement program?

Are you currently in a treatment program? Please include names of Case Managers and their contact information.

What is your relapse plan? Please include the contact number and name of the person who will pick you up in the instance of relapse?

Are you on (Medication Assisted Treatment) MAT?

Yes

What is your Sober or Clean date?

YYYY

What date would you like to move in?

YYYY

Please enter any other information about yourself or your situation that you feel we need to know.

Signature

First Name

Last Name

Recovery Housing Application

Motivation comes from within —

and we are here to help you activate it.

Apply for Ben’s House

Recovery Housing Application

You belong here. ♡

About

Apply Today!