Residential Application
First Name
*
Last Name
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
How Did You Hear About SIR House
*
Website
Internet Search
Detox / Rehab / Hospital Referral
Current or Former Resident
Sponsor
Friend
Legal Entity (Court, Probation, Etc)
Other
Date of Birth
*
-
Month
-
Day
Year
Date
Sobriety Date
*
-
Month
-
Day
Year
Date
Requested Move in date
*
-
Month
-
Day
Year
Date
Prefered Location
*
Please Select
Dewberry
Pasadena
Broadway
No Preference
Where are You Currently Residing?
*
Please Select
Homeless
Friend
Family
Treatment Center
Sober Living
Hospital
Jail/Prison
Other
Have you been to Treatment/Rehab/Detox?
*
No
Yes
Name of Facility
*
Current or Last Treatment Facility Discharge Date
*
-
Month
-
Day
Year
Date
What is Your drug(s) of choice
*
Adderall
Alcohol
Amphetamines
Cocaine (all forms)
DMT
Ecstacy
Fentanyl
Herion
Hydromorphine
Klonopin
Kush
Librium
Lorazepam
Marijuana
Meth
Methadone
Mushrooms
Opioids
Pain Pills
PCP
Peyote
Ritalin
Spice
Suboxone
Valium
Xanax
Other
Are You Pregnant?
*
No
Yes
Are You Currently on a Methadone or Suboxone Program?
*
No
Yes
Are You Currently Taking Prescription Medications Or Should You Be?
*
No
Yes
Are Any of Your Prescriptions Narcotics or Controlled?
*
No
Yes
Can You Manage Your Medication or Do You Need Supervision?
*
No, I need supervision
Yes
Medications: List Only Prescription Medications
*
Name of Medication
Diagnosis
Strength
1
2
3
4
5
6
Can You Climb to a Top Bunk?
*
No
Yes
Please Check Any That Apply
*
Disability or Social Security
Employed
Enrolled In School
None of the Above
Please Check the Items You Currently Have
*
Current TDL or ID
Social Security
Health Insurance
Birth Certificate
None of the Above
Are You Employed?
*
No
Yes
Name of Employer
*
Employer Phone Number
*
Please enter a valid phone number.
Do you have a Vehicle?
*
No
Yes
Vehicle Year, Make & Model
*
Please Check All Items Regarding the Vehicle That Apply
*
Current Auto Insurance
Current Inspection
Current Registeration
None of the Above
Are You WIlling to Participate in a 12 Step Program?
No
Yes
Do You Have an AA or NA Sponsor
*
No
Yes
Name of Sponsor
*
Do You Have Any Legal Issues?
*
No
Yes
Type of Legal Issue
*
CPS Case
Drug Court
Parole
Pending Charges
Probation
Warrants or Fines
Please List Legal Charges
*
Name of Legal Officer or Caseworker
*
Legal Officer or Caseworker Phone Number
*
Please enter a valid phone number.
In Case of Emergency Contact (ICE)
*
ICE Phone Number
*
Please enter a valid phone number.
ICE Relationship
*
List All Allergies or Enter None
*
Submit
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