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Recovery Homes

The Leamington Community Hope Centre runs a Women's sober living house as well as a Men's recovery home. If you are interested in applying, please fill out the application below.

If you have any questions, please reach out to Robert Sandwith, our Manager of Recovery Care, at rsandwith@lchope.ca

REcovery Home Application

First name*

Last name*

Date*

Year

Month

Day

Phone Number*

Birthday

Year

Month

Day

Gender*

Emergency Contact Name, Phone Number and Relationship*

Current Source of Income*

Length of Employment if Applicable

Healthcare Coverage*

Please list all medication you are currently taking*

What is your current or most recent housing situation?*

If you selected other, please describe

Do you have any current legal issues?*

No issues

Family Court Matters

Criminal Court Matters

On Probation

Pending

Actively Involved

Active CAS Involvement

Conditional Sentence

Awaiting Sentencing

Sentenced

Other

Please select all that apply

If you selected other, please describe

Do you have any sex related charges, convictions or are you on the sex offender registry?*

Yes

No

Areas of Concern*

Substance Abuse

Emotional/Psychological Violence

Sexual Violence

Physical Violence

Intimate Partner Violence

Mental Health Diagnosis

Anxiety Disorder

Psychotic Disorder

Eating Disorder

Process Addiction

Mood Disorder

Personality Disorder

Social Relationship

Impulse Control Disorder

Suicidal Ideation

Self-Harm

Financial Difficulty

Low Education

Learning Disability

Anger/Violence

Emotional Stability

Activities of Daily Living

Lack of Government ID

Aggression

Family Relationship

Dating Relationship

Please select all that apply

Diagnoses (please put NA if it does not apply)*

Previous Addiction Treatment History*

Private Community-Based Treatment

Private Residential Treatment

Public Community-Based Treatment

Public Residential Treatment

Abstinence Based Self Treatment

Abstinence Based Group Treatment

Harm Reduction Based Self Treatment

Hard Reduction Based Group Treatment

Correctional Facility Based Treatment

Court Ordered Treatment (Any Type)

Other

Please select all that apply

If you selected other, please describe

Please give approximate date of previous treatment

Year

Month

Day

Please select your highest level of education*

Please select all substance you have used in the past 12 months*

Alcohol

Glue/Inhalant

Opioids/Fentanyl

Amphetamines/Stimulants

Cocaine

Hallucinogens

Over the Counter Codeine

Barbiturates

Crack

Prescription Opioids

Heroin

Cannabis

Benzodiazepines

Ecstasy

other Psycho-Actives

Steroids

Tobacco

Gambling

Sex/Pornography

Internet/Gaming

Other

If you selected other, please describe

Is there anything else you would like to share with us?

Contact Us

58 Erie Street South
Leamington, ON, N8H 3B1

519-326-9280

info@lchope.ca
Registered Charity Number: 703123901 RR 0001

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