Resident Application

"Coburn is helping me find a new life and now I don't have to go back to what was, nor can anyone force me to." - D.B., Coburn Place resident

If you or someone you know needs our services, print out the resident application below. Once it has been completed, it can be mailed, faxed, or dropped off in person to us.

If you have any further questions regarding the program or residency, please contact us at 317-923-5750 or by email.

Download the RESIDENT APPLICATION in .pdf format.

*You will need Adobe Reader to view and print the application. If you do not have Adobe Reader, you may download it for free.

Please mail, drop-off or fax your completed application to:

Coburn Place Safe Haven
604 E. 38^th Street
Indianapolis, IN 46205
317-923-5750 – phone
317-921-1946 – fax