Application

Brian's

Safehouse

Birth Date *

Name of Applicant *

Email Address of Applicant (Enter N/A if you do not have one.) *

After you submit this application, we will call you to do a phone interview. We will contact you as soon as possible. If you do not receive a call within two to three days, please contact us at 304-763-7655. Thank you.

Email Address of the Person Filling Out the Application. (If this does not apply, enter N/A.) *

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Address of Applicant *

Name of person filling out the application. (If you are the applicant, you may write in "Same" or "N/A.") *

What can we do to help you with the issues that you are facing? *

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Phone number of person filling out the application. (If you are the applicant, you may write in "Same" or "N/A.") *

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Why do you want to become part of the substance use disorder recovery program at Brian's Safehouse? *

Applicant's Signature: *

Are you serious about recovery, yearning to be free of any chemical dependency? Brian’s Safehouse is about restoration and freedom, about becoming a man who can have self-respect and the respect of others. We are a faith-based, 12-month, residential substance use disorder recovery program. Our recovery program builds abilities and provides opportunities: we help build in you the tools that give you the ability to live a sober life and the opportunity to learn life skills that will enable you to become a productive member of society. Brian’s Safehouse works with our residents to rebuild family relationships, work through legal issues, and to become men who can be successful employees. We are a tobacco-free program and campus, therefore we have a doctor-directed program available to assist our residents to become free of nicotine.

Would you be interested in becoming involved in the recovery program at Brian’s Safehouse? If the answer is “yes” please fill out the following application. *All fields are required in order to be able to submit the application. If the application will not submit, please check for unanswered questions.

Today's Date and Time *

Phone *

​Brian's

Safehouse

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Brian's