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Referral Form

Relationship to Applicant
Requested Residence: Men’s or Women’s Housing
Is the applicant medically and psychiatrically stable for independent shared housing?
Is the applicant using MAT or another prescribed medication that requires secure storage in a lockbox?
Does the applicant have a known history of violence, arson, sexual offenses, or other safety concerns relevant to shared housing?
Proposed Payment Source
Has the applicant agreed to be contacted by Jax Recovery Homes?

Thank you for partnering with us. A member of our team will contact you within 24 hours to discuss bed availability and other placement details. For urgent inquiries, please call or text (904) 788-1772.​

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Every applicant must complete an individual screening and agree to the residence’s standards and financial requirements. Submission does not guarantee placement; however, we make every reasonable effort to accommodate appropriate referrals.

Submit only the minimum information necessary for an initial housing inquiry. Do not include medical or counseling records, diagnoses, detailed medication information, Social Security numbers, insurance information, drug-test results, or detailed criminal-history documents. Please confirm that you have appropriate authorization or another lawful basis to provide the information and that the prospective resident has agreed to be contacted when appropriate. Review our Privacy Policy before submitting.

Thank you for submitting the referral. A member of the Jax Recovery Homes team will contact you within 24 hours. For urgent placement inquiries, please call or text (904) 788-1772.​

Have a great day!

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