Application for Residency - Vittoria House

Section 1 of 9 - Contact Information 11%

Before You Begin A minimum of 30 days free from alcohol and all non-prescribed substances is required. Answer every question honestly - any misrepresentation will disqualify your application. Submission does not guarantee placement; a staff member will contact you to schedule your interview.

Section One

Contact Information

Legal name - Address - Emergency contacts - Physician

First Name *

Middle Name

Last Name *

Street Address *

Address Line 2 (Apt, Unit, Facility)

City *

State

ZIP Code

Cell Phone *

Alternate Phone

Email Address *

Emergency Contact - Primary

Full Name *

Relationship *

Phone *

Emergency Contact - Secondary

Full Name

Relationship

Phone

Physician / Primary Care Provider

First Name

Last Name

Practice / Clinic Name

Practice Address

Practice Phone

Section Nine

Disclosures & Consent

Please read carefully before affirming

Connecticut DMHAS Required DisclosureVittoria House is a non-clinical peer recovery residence operated by Dime Shac Foundation Inc. This facility is not a licensed treatment program and does not provide medical, clinical, or therapeutic services. We provide safe, structured, substance-free housing and peer support. For clinical care, contact a licensed provider or call 211 Connecticut.

NARR Resident RightsAs a resident of a NARR-certified recovery residence, you have the right to be treated with dignity and respect; receive a copy of house rules; a fair grievance process; continue lawfully prescribed medications including MAT; privacy of personal health information; and freedom from discrimination.

Program Rules AcknowledgmentResidency requires complete abstinence from alcohol and all non-prescribed drugs; weekly house meetings; random drug and alcohol testing; curfew and sign-in/sign-out compliance; participation in recovery-support activities; meeting financial obligations; and respectful conduct toward all staff and residents. Violations may result in immediate discharge.

Witness Acknowledgment

Witness Full Name *

Witness Phone *

Date *

Witness Relationship to Applicant

* Denotes required field

Application Received

Thank you for taking this step. A member of the Vittoria House team will reach out to you within 24 to 48 hours to schedule your interview.

Questions? Call 860.698.5540 or email info@hartfordrecovery.org