RESIDENTIAL APPLICATION
Name
*
First Name
Middle Initial
Last Name
Age
*
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
*
Male
Female
Phone
*
E-mail Address:
*
example@example.com
Marital Status
*
Please Select
Married
Divorced
Single
Widowed
Common Law
If you have a spouse or partner, please provide their name:
Spouse or partner home address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If you have children, please provide their name(s) and age(s):
Driver's License #:
State Issued:
Expiration Date:
State ID or Passport #:
Previous Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Are you able to work full or part time?
*
Yes
No
If unable to work, explain:
Present or Recent Employer:
*
Employer Phone
*
Employer Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name:
*
Emergency Contact Phone #:
*
Emergency Contact Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have means of transportation?
*
Yes
No
If yes, what type?
Car
Truck
Motorcycle
Other
If yes, license plate # and state:
How were you referred to the Act Like Men Sobriety House?
*
Agency, Facility, Friend, Family, Parole Office, Internet, other resident, etc.
Do you need SNAP (supplementary food program)?
*
Yes
No
Do you have medical insurance?
*
Yes
No
Do you need Social Security or Driver's License assistance?
*
Yes
No
Are you on probation?
*
Yes
No
Do you need a primary care physician?
*
Yes
No
Do you need a dentist:
*
Yes
No
Do you need counseling?
*
Yes, and I am in active counseling.
Yes, and I am not presently in counseling.
No
If you are in active counseling, what is the organization's name?
Counselor Name:
First Name
Last Name
Counselor Phone #:
Counseling Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have other social service needs not mentioned?
Have you ever worked a 12-step program of recovery?
*
Yes
No
If yes, what program?
Sponsor Name:
Sponsor Phone #:
What is your highest degree of education?
*
Are you a military veteran?
*
Yes
No
If yes, what branch of service?
Have you lived in a Sobriety House before?
*
Yes
No
If yes, what is the name and location?
What were your preferred substances?
*
What other drugs or alcohol have you used in the last 6 months?
*
Have you completed detox?
*
Yes
No
If yes, when?
-
Month
-
Day
Year
Date
If yes, where?
What is your sobriety/clean date?
*
-
Month
-
Day
Year
Date
What is your longest period of sobriety?
*
What was your longest period of active use?
*
TREATMENT HISTORY
Name of Treatment Center #1:
Treatment Center Phone #:
Treatment Center Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Started:
-
Month
-
Day
Year
Date
Date Ended:
-
Month
-
Day
Year
Date
What is the reason you left?
Name of Treatment Center #2:
Treatment Center Phone #:
Treatment Center Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Started:
-
Month
-
Day
Year
Date
Date Ended:
-
Month
-
Day
Year
Date
What is the reason you left?
Name of Treatment Center #3:
Treatment Center Phone #:
Treatment Center Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Started:
-
Month
-
Day
Year
Date
Date Ended:
-
Month
-
Day
Year
Date
What is the reason you left?
Name of Treatment Center #4:
Treatment Center Phone #:
Treatment Center Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Started:
-
Month
-
Day
Year
Date
Date Ended:
-
Month
-
Day
Year
Date
What is the reason you left?
MEDICAL INFORMATION
Prescriptions
List medications you are currently using.
Medication #1:
Dosage:
Quantity:
Frequency:
Notes:
Medication #2:
Dosage:
Quantity:
Frequency:
Notes:
Medication #3:
Dosage:
Quantity:
Frequency:
Notes:
Medication #4:
Dosage:
Quantity:
Frequency:
Notes:
Medication #5:
Dosage:
Quantity:
Frequency:
Notes:
Primary Physician:
First Name
Last Name
Primary Physician Phone #:
Please enter a valid phone number.
Primary Physician City/State:
Preferred Hospital:
Preferred Hospital City/State:
Dentist:
First Name
Last Name
Dentist Phone #:
Please enter a valid phone number.
Dentist City/State:
Do you have health insurance?
*
Yes
No
If yes, company:
ID #:
Group #:
Contact Phone (back of card):
Do you have Medicare or Medicaid coverage?
*
Yes
No
If yes, plan #:
ID #:
List any known medical issues:
Have you been tested for Hepatitis C?
*
Yes
No
If yes, were you positive or negative?
*
Positive
Negative
Have you been tested for Tuberculosis?
*
Yes
No
If yes, were you positive or negative?
*
Positive
Negative
Have you been tested for HIV?
*
Yes
No
If yes, were you positive or negative?
*
Positive
Negative
What, if any, known allergens do you have?
*
Do you have a history of seizures?
*
Yes
No
If yes, date of last seizure?
Have you ever overdosed?
*
Yes
No
If yes, how many times?
Have you ever abused (check all that apply):
Alcohol
Cocaine
Amphetamines
Heroin
Crack
Hallucinogens
THC
Methadone
Buprenorphine
Benzodiazepine
Ecstacy
Pain Medication
Molly
Bath Salts
K2
Gabapentin
PCP
LSD
Suboxone
Glue
Inhalants
OxyContin
Percocet
Codeine
Dusting
Fentanyl
Methamphetimines
Other
Have you ever attempted suicide?
*
Yes
No
If yes, how many attempts?
If yes, date of most recent attempt:
-
Month
-
Day
Year
Date
LEGAL INFORMATION
Have you committed a felony?
*
Yes
No
If yes, please explain:
Are you part of any specialized courts (DUI, substance abuse, mental health, veterans, etc.)?
*
Yes
No
If yes, which court?
Are you on state or federal parole?
*
Yes
No
If yes, please explain:
If yes, your parole officer:
First Name
Last Name
If yes, parole officer's phone:
Please enter a valid phone number.
Are you on county probation?
*
Yes
No
If yes, please explain:
If yes, your probation officer's name:
First Name
Last Name
If yes, your probation officer's phone #:
Please enter a valid phone number.
Have you ever been charged with a DUI?
*
Yes
No
If yes, how many times?
DUI #1 State:
DUI #1 Date:
DUI #2 State:
DUI #2 Date:
DUI #3 State:
DUI #3 Date:
Are any charges pending against you?
*
Yes
No
If yes, what charges?
Are you a registered sex offender?
*
Yes
No
Do you have any assault charges on record?
*
Yes
No
If yes, please explain:
Why do you want to live at the Act Like Men Sobriety House?
Submit
Should be Empty: