Resident Application
Personal Information
Name
First Name
Last Name
Gender
Please Select
Female
Male
Date of Birth
ID/Driver License Number / State Issued
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
COVID Vaccination Date(s)
Date Expected to Enroll
Race
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
Please Select
Hispanic or Latino or Spanish Origin
Not Hispanic or Latino or Spanish Origin
Height
Weight
Education Completed
Religious Preference
Medications
Name/Dosage/ Frequency
Prescribing Doctor
Diagnosis
How long used
1
2
3
4
5
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Emergency Contact / Sponsor Information
Emergency Contact Name and Relationship
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Preferred Contact Method
Phone, Email, Text
Sponsor Name/ Relationship/ Length of relationship
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Preferred Contact Method
Phone, email, text
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Referral Information
How did you hear about Open Arms Sober Living?
Referral Source / Phone / Email
Reason for Referral
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Financial and Logistics
Will you have a vehicle?
Yes
No
If yes, please provide details about the vehicle
Color
Year
Make
Model
License Plate
Vehicle
Will you be financially responsible for your own program fees?
Yes
No
Will you have support from family/other for your program fees?
Yes
No
Are you employed?
Yes
No
If yes, where?
Are you a recovering alcoholic?
Yes
No
Are you a recovering drug addict?
Yes
No
Check all those you are planning to attend
Aftercare Program
IOP Program
90 days of meetings
What is your sobriety date
Are you discharging from a substance abuse program?
Yes
No
If yes, list the facility name, address, counselor and phone number
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Legal History
Do you have any pending court cases other than moving violations?
Yes
No
If yes, please explain: (bond, probation, pending court case)
Have you ever been convicted of a felony?
Yes
No
If yes, please explain:
Have you ever been accused or convicted of a sexual offense?
Yes
No
Previous Treatment / Sober Living Organizations
Name
Dates
1
2
3
4
Home Group
Name
Address
Day/Time
Zoom
Home Group
I affirm that all information I provided above is true and correct.
Applicant's Signature
Date Signed
Submit
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