Join AzRHA – My AzRHA

Membership Application

Please take your time and fill out each section of the application. Failure to provide complete and honest answers to these question may prolong the application process.

Organizational Information

Company Name / DBA

Legal Entity Name

Owners of Record

Specify Organziational Type

Year Founded

Company Billing Address

Street

City

State

Zip

Company Mailing Address

Street

City

State

Zip

Phone

Website

Principal contact person

Name

Title

Phone Number

Email Address

Will your organization attend the training workshops within 90 days of certification?

Yes No

Does applicant own or operate a licensed or certified addiction or mental health program or facility?

Yes No

Specify

Do any of the owners identified in this application have an ownership interest in or any sort of business relationship with a licensed, independent use, confirmatory lab?

Yes No

If owners have any ownership in any other businesses in the recovery industry please disclose here:

Do you operate other types of housing?

Yes No

Specify type and facility

Describe your business

Please fill out all fields to proceed

II Management and Staff Information

All owners, managers and staff are required to register with the credentialing entity (AzRHA). If the legal entity is a corporation with a large Board of Directors or is publically traded as is owned by a broad body shareholders, then the CEO and CFO may register as "Owners of Record". For each contact entered, a unique email address is required and a contact phone number that will be directly answered by that contact.

Main switchboard phone numbers and general inbox addresses are not permissible in the contact section of this application.
Failure to list all owners, managers, and staff constitutes a fraudulent application that may result in denial and/or revocation of your certificate of compliance.

Name

Title

Direct Phone

Direct Email

Special Training/Licensure

III Standards, Code of Ethics, Dispute Resolution

Do you maintain formal standards for the operation of your recovery residences?

Yes No

Do you maintain a code of ethics to which all members subscribe, or do your standards contain provisions equivalent to a code of ethics?

Yes No

Do you agree to adopt the AzRHA Standard for Recovery Residences for all recovery residences operated by your organization?

Yes No

Do you have a defined process for resolving complaints from residents and the public?

Yes No

Do you maintain and follow procedures for logging and retaining records of complaints about your residences, and the manner in which they were resolved?

Yes No

IV Support for AzRHA Mission

Are you willing to fully participate in AzRHA organizational activities?

Yes No

Are you willing and able to support AzRHA-sponsored research initiatives?

Yes No

Are you willing and able to contribute financially to the operation of NARR by payment of applicable annual affiliate fees?

Yes No

Do you intend to conform to affiliate requirements which are enacted by AzRHA for adoption by its affiliates?

Yes No

Do you agree to cooperate with PARR in efforts to resolve complaints received by PARR about the affiliate or about its individual members?

Yes No

Have you read and do you understand the residence certification requirements?

Yes No

Have you reviewed the health, safety and management requirements?

Yes No

Have you read, and do you agree to abide by the Code of Ethics?

Yes No

Have all responsible persons (see note) read, and signed, the Code of Ethics?

Note: A 'responsible person' is anyone in a position of authority or responsibility within the residence, including managers, house captains, senior residents, peer leaders and heads of household.

Yes No

V Residences

General Information

Residence Name

County

Address

Manager Name

Housing Capacity Information

Number of Units

Number of Bedrooms

Number of Beds

Number of Bathrooms

Other space available?

Yes No

Pool available?

Yes No

Do you welcome Medically Assisted Treatment in your residences?

Yes No

Is your residence abstinence based?

Yes No

Recovery Path

12 Step Faith Based Celebrate Recovery SMART

Is food included in the fees?

Yes No

Do you manage resident funds?

Yes No

Costs

Administrative Fee

Deposit Amount

First and Last Amount

Pro-rated Amount

Billing Frequency

Shared Room Amount

Private Room Amount

Describe this residence

Residence Pictures

Thank you for your application - we will get in touch soon!

The Next Step is to pay the Application Fee. Please visit the link below.

Payment Page