ALM Sobriety House

  • RESIDENTIAL APPLICATION

  • Gender*
  • Format: (000) 000-0000.
  • Are you able to work full or part time?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you have means of transportation?*
  • If yes, what type?
  • Do you need SNAP (supplementary food program)?*
  • Do you have medical insurance?*
  • Do you need Social Security or Driver's License assistance?*
  • Are you on probation?*
  • Do you need a primary care physician?*
  • Do you need a dentist:*
  • Do you need counseling?*
  • Format: (000) 000-0000.
  • Have you ever worked a 12-step program of recovery?*
  • Format: (000) 000-0000.
  • Are you a military veteran?*
  • Have you lived in a Sobriety House before?*
  • Have you completed detox?*
  • If yes, when?
     - -
  • What is your sobriety/clean date?*
     - -

  • TREATMENT HISTORY

  • Format: (000) 000-0000.
  • Date Started:
     - -
  • Date Ended:
     - -
  • Format: (000) 000-0000.
  • Date Started:
     - -
  • Date Ended:
     - -
  • Format: (000) 000-0000.
  • Date Started:
     - -
  • Date Ended:
     - -
  • Format: (000) 000-0000.
  • Date Started:
     - -
  • Date Ended:
     - -

  • MEDICAL INFORMATION

  • Prescriptions

    List medications you are currently using.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you have health insurance?*
  • Do you have Medicare or Medicaid coverage?*
  • Have you been tested for Hepatitis C?*
  • If yes, were you positive or negative?*
  • Have you been tested for Tuberculosis?*
  • If yes, were you positive or negative?*
  • Have you been tested for HIV?*
  • If yes, were you positive or negative?*
  • Do you have a history of seizures?*
  • Have you ever overdosed?*
  • Have you ever abused (check all that apply):
  • Have you ever attempted suicide?*
  • If yes, date of most recent attempt:
     - -

  • LEGAL INFORMATION

  • Have you committed a felony?*
  • Are you part of any specialized courts (DUI, substance abuse, mental health, veterans, etc.)?*
  • Are you on state or federal parole?*
  • Format: (000) 000-0000.
  • Are you on county probation?*
  • Format: (000) 000-0000.
  • Have you ever been charged with a DUI?*
  • Are any charges pending against you?*
  • Are you a registered sex offender?*
  • Do you have any assault charges on record?*
  • Should be Empty: