top of page
burchyr.png

Burch House Interest Form

Are you completing this form for yourself or someone else?
Myself
Family/Friend
Professional Referral
Current Living Situation
Treatment Center
Recovery Residence
With family/friends
Unhoused
Other
Desired move-in timeframe
ASAP
Within 30 days
30-90 days
Just gathering information
Are you currently in recovery from substance use?
Yes
No
If yes, what is your recovery date?
Month
Day
Year

Submitting this form does not guarantee admission. A member of our team will contact you to discuss eligibility and next steps.

bottom of page