Buffalo House Application

 
   
SUBMIT YOUR APPLICATION

By submitting this application, Buffalo House staff will be notified of your interest in our program and a member of our staff will be in contact with you shortly. Please note, applications are accepted on a first come, first serve basis.
     
indicates required fields
   
First Name:
Last Name:
Date of Birth:
Pick A Date
Current Phone:
Email:  
Referred to Buffalo House By:
Requested Move-In Date:
Pick A Date
Sobriety Date: Pick A Date
Current or Most Recent Facility:  
Counselor's Name:

Counselor's Phone: