Skip to main content

APPLY NOW

Briggs Restorative & Wellness Home Group Rental Application

Please enter all information and we will contact you within 24-48 hours.

Pre-Screen Application

Name(Required)
MM slash DD slash YYYY
Gender(Required)

Drop files here or
Max. file size: 2 GB.
    Employment Status
    Demographic Status
    MM slash DD slash YYYY
    Were you referred
    Emergency Contact(Required)
    You must provide a valid contact
    History of suicidal attempts/ideations(Required)
    History of violent/ assaultive behavior?(Required)
    History of malicious behavior such as setting fires?(Required)
    History of alcohol use, abuse or dependency?(Required)
    History of drugs use, abuse or dependency?(Required)
    Have you ever been diagnosed with or undergone treatment for any of the following?
    Download PDF