Apply for a bed

It takes about 5 minutes. Our admissions team will call you, usually within one business day. If you need help right now, call us.

About you

First name

Last name

Phone

Email (optional)

Date of birth

Clean / sobriety date (optional)

Your situation

Where are you staying now? House preference Are you on probation or parole, or involved with a court? (optional) How do you plan to pay? Health insurance (optional)

Insurance company / plan (optional)

Member / policy number (optional)

How did you hear about us? (optional) Anything else you'd like us to know? (optional)

Emergency contact (optional)

Name

Phone

I agree that Chelsea's House may contact me by phone, text or email about this application. Your information is kept private and is only used for admissions.

Apply for a bed

About you

Your situation

Emergency contact (optional)

Thank you — we got your application.