Recovery Housing Residences Registration Form

Name of recovery housing residence (if incorporated, this is the name filed with the Ohio Secretary of State's office) *

Name of recovery housing residence is required

Additional name(s) recovery housing residence does business under; if not applicable, write NA in box (e.g. names used to advertise the recovery housing residence in the community)  *

Additional name is required. If not applicable, write NA in box.

Ohio Secretary of State's entity number (Ohio Secretary of State business search) *

Ohio Secretary of State's entity number is required. If not applicable write, NA in box.

Address of recovery housing residence *

Street address:  City:  County:  Select... Adams Allen Ashland Ashtabula Athens Auglaize Belmont Brown Butler Carroll Champaign Clark Clermont Clinton Columbiana Coshocton Crawford Cuyahoga Darke Defiance Delaware Erie Fairfield Fayette Franklin Fulton Gallia Geauga Greene Guernsey Hamilton Hancock Hardin Harrison Henry Highland Hocking Holmes Huron Jackson Jefferson Knox Lake Lawrence Licking Logan Lorain Lucas Madison Mahoning Marion Medina Meigs Mercer Miami Monroe Montgomery Morgan Morrow Muskingum Noble Ottawa Paulding Perry Pickaway Pike Portage Preble Putnam Richland Ross Sandusky Scioto Seneca Shelby Stark Summit Trumbull Tuscarawas Union Van Wert Vinton Warren Washington Wayne Williams Wood Wyandot Zip code:  Street Address is required City is required County is required Zip Code is required Invalid zip code

This address already registered. Please enter another address or change the answer of 'Is this form an update to a previously submitted form?' to 'Yes'

Full name of the person or government entity operating the residence *

Full name of operator is required.

Full name of the parent company (if not applicable, write NA) *

Full name of the parent company is required. If not applicable, write NA in box.

Full name of affiliated behavioral health organization (if not applicable, write NA) *

Full name of affiliated behavioral health organization is required. If not applicable, write NA in box.

Primary telephone number for recovery housing residence operator *

Primary telephone number for recovery housing residence operator is required. Please Input valid phone number

Email address for recovery housing residence operator *

Email address for recovery housing residence operator is required. Please Input valid email address

Website address for recovery housing residence (if not applicable, write NA) *

Website address for recovery housing residence is required. If not applicable, write NA in box.

Is recovery housing residence already open? *

Yes No

Please answer is the recovery housing residence already open?

Number of beds in the home for residents *

Number of beds in the home for residents Please enter valid number for number of beds

Is your recovery housing residence currently accredited or certified, not currently accredited or certified, or actively in process of attaining accreditation or certification? *

Select... Currently accredited or certified Not currently accredited or certified Actively in process of attaining accreditation or certification

Please select accreditation or certification status

What NARR level is this Recovery Residence? *

Select... 1 2 3

Please select NARR level

What population does this home serve? *

Men Women Families with Children Men with Children Women with Children LGBTQ+ Other

Please select at least one population

Does this home specialize in serving specific populations? *

Yes No

Please answer Does this home specialize in serving specific populations?

Is this residence handicap accessible? (*examples - ramp, accessible bathroom, accessible kitchen) *

Yes No

Please answer is this residence handicap accessible

Is this form an update to a previously submitted form? *

Yes No

Please answer is this update form

Additional comments:

Fraud warning: Any registrant who knowingly submits false or misleading information in this process is subject to criminal or civil penalties. By submitting and signing this document, registrant acknowledges and confirms information contained herein is true and accurate.

Print name (individual completing form) * Contact email * Contact telephone # * Date Required Email is required Please input valid email Phone is required Please input valid phone