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 feel you or someone you know may qualify for our program, 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 our Women's Services Director, Deb Williams, deb@coburnplace.org or 317-923-5750.

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

Download the RESIDENT APPLICATION in .pdf format.

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