top of page

Home
Our Program
Support Us
Contact
More

Use tab to navigate through the menu items.

OUR DOCUMENTS

Please download, print and complete the Noah's House Inc. application.

You can fax the completed application to 717-552-2258, or by e-mail: info@noahshouse.org, or mail it to:

Noah's House Inc.

PO Box 791

Chambersburg, PA 17201

NHI Application

There IS Always Hope

First name*

Last name*

Address*

Phone*

Birthday*

Month

Day

Year

Marital Status (Select all that apply)*

Single

Married

Separated

Divorced

Widowed

Are you an Alcoholic?*

Yes

Date of last drink

Are you addicted to drugs?*

Yes

Date of last use

Are you employed?*

Yes

If yes, who is your employer?

If you do not have a job, will you get one?

Yes

If yes, how will you get one?

Are you getting welfare or other non-job related income?*

Yes

If yes, what is it?

What is your monthly income?*

What do you expect your income to be next month?*

Do you have a medical doctor?*

Yes

If yes, list the doctors name and phone number

Do you take prescription drugs? If yes, list the drugs and the reason the drug has been prescribed

Are you on probation?*

Yes

Officer/Agent Name

Officer/Agent Phone Number

Are you on parole?*

Yes

Are you a registered sex offender?*

Yes

What is your requested move in date?*

Why is this the date you have requested?*

Have you ever previously enrolled in a Noah's House Inc. recovery program?*

Yes

Social Security #*

Drivers License #

Drivers License issued by what state?

Drivers license expiration date

Contact Us

P.O. Box 791

Chambersburg, PA 17201
info@noahshouse.org

Connect with us

Facebook

Instagram

YouTube

Thanks for submitting!

Noah's House Inc., is a 501(c)(3) nonprofit organization.

Noah's House Inc. EIN: 81-2810826

Noah's House Inc Recovery Homes Are Licensed By

The Pennsylvania Department of Drug and Alcohol Programs

GET ADOBE READER

If you are unable to view PDFs, please download Adobe Reader.

and in partnership with the following entities:

NHI Application

This Website

bottom of page

OUR DOCUMENTS

There IS Always Hope

SUBSCRIBE

Noah's House Inc., is a 501(c)(3) nonprofit organization.

Noah's House Inc. EIN: 81-2810826