Applicant Info (demographics):

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First Name *

Last Name *

***Applicant Email ONLY ***IF YOU ARE A SW OR CASE MANAGER and are filling this out for a client, DO NOT PUT YOUR EMAIL HERE. LEAVE BLANK IF YOU DO NOT HAVE THE APPLICANT'S EMAIL.

***Applicant Phone ONLY ***IF YOU ARE A SW OR CASE MANAGER and are filling this out for a client, DO NOT PUT YOUR PHONE # HERE. LEAVE BLANK IF YOU DO NOT HAVE THE APPLICANT'S PHONE #.

Date of birth *

Street Address *

City *

State *

Postal code *

Marital Status *

Married
Divorced
Single
Widowed
Separated
Partner
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Driver's License # or State ID #: (if suspended or revoked, please put N/A) *

Sobriety Date *

Addiction History (please list all drugs used): *

Do you have a Case Manager? *

Yes

Case Manager Name

Case Manager Email Address:

Case Manager Phone #:

Have you ever been in a treatment program? *

Yes

If yes, what was the most recent treatment start date: *

Length of Stay

Did you complete the program?

Yes

Treatment center name & address:

Have you ever lived in a recovery home? *

Yes

Recovery home name & address:

Reason for leaving

Are you currently attending 12 step meetings? *

Yes

If yes, how many per week?

Education: *

No HS Diploma & No GED

High School Diploma or GED

Some College

College Graduate

Other

Why do you want to live in a sober house? *

How did you hear about us? *

What other information should we consider when reviewing your application?

Filler

Emergency Contact Information

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone #: *

Emergency Contact Address:

Filler

Financial Information

Are you capable of paying rent or monthly dues? *

Yes

Other

How will rent, dues, or any other fees be paid? *

Are you currently employed? *

Yes

Current Monthly Income $ *

Current Employers Name & Address

Are you capable of working/volunteering? *

Yes

List any Work Experience (What do you do for employment. Trades, Degrees, Special skills and Training) *

Filler

Chemical Use History / Legal Involvement

Are you court ordered to be in a sober house: *

Yes

Criminal History (Check all that apply from your lifetime) *

I have no criminal history

I am currently on Probation

I have been charged with a Violent Crime

I have committed or have been charged with Arson

I have a Sex Crime conviction

I am on Ankle Monitoring

Other

If you have answered yes to any of the above, state in detail the circumstances of the offense(s)

Do you have a Parole Officer / Probation Agent? *

Yes

If yes, what is their name and contact information?

Number of lifetime DWI's / DUI's: *

Have you previously been convicted of a felony? *

Yes

If yes, explain the offense, date, and state/county:

Filler

Physical & Mental Health

Please list ALL allergies *

Please list ALL medications in your possession. These are both prescription and non-prescription (such as Tylenol, cold medication, etc.) *

Are you under a physician’s care? *

Yes

Doctor(s) Name and Phone number:

Are you under the care of: *

Psychologist

Psychiatrist

Therapist

Other

None

If yes, what are their Name(s) and Phone number(s):

List any Psychiatric diagnosis*

Have you ever planned suicide? *

Yes

Have you ever attempted suicide? *

Yes

Please list any medical issues/ medical concerns that an emergency response team may need to know about (allergies, high BP, etc.):

Filler

References

Please list two (2) references that are familiar with your life and current situation.

Reference #1 Name *

Reference #1 Years Known *

Reference #1 Phone number: *

Reference #1 Relationship to you: *

Reference #1 Address:

Reference #2 Name

Reference #2 Years Known:

Reference #2 Phone number

Reference #2 Relationship to you

Reference #2 Address

Filler

Agreements

Any comments or additional information you would like to add:

Upon acceptance, you will be expected to enter into an Agreement wherein you will agree to abide by certain rules and standards of conduct. Do you acknowledge this expectation? *

Yes

Applicant Signature *

Clear

Today's Date *

Captcha

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