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Careers
Apply

Full Name

Attorney Parole Officer Family Member Caregiver Court Representative

Corporate Name/Title

DOB

Next of Kin/emergency contact:

Phone

Next of Kin/emergency contact:

Phone

Offenses that require registration?

Yes No

Are you taking medication?

Yes No

If yes, do you need assistance with taking your medication?

Yes No

Medications you are taking:

Do you suffer for any Psychological Problems?

Yes No

If yes, what

If yes list medications

HIV Status

Positive Negative don’t know

Recovering from Alcohol?

Yes No

Recovering from Drugs?

Yes No

Must be able to meet the monthly service fee obligations

Follow the house rules to ensure a peaceful and tranquil environment. Disturbance of such will be grounds for immediate relocation.

Do you have any pending court cases? Yes or No If yes, next court

Date

Charge

Do you receive SSI or Disability?

Yes Not

If not, are you employable?

Yes No

Do you have any medical restrictions?

Yes No

Proof of Negative Covid-19 Report

Want to book an appointment or learn more about us?

lOCATION

Health & Wellness

Main campus & office Valhermoso Springs
North Huntsville campus
North East Huntsville campus

Contact Us

info@serenitycommunities.org
(256)957-8332

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