Stewards of Recovery
Sober living application
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
/
Month
/
Day
Year
Date
Gender
*
M
F
Age
*
Ethnicity/Race
*
Marital status
Please Select
Domestic Partner
Married
Single
Divorced
Widow
Highest Level of education completed:
*
Are you employed?
*
Yes
No
Where?
Gang Affiliation?
*
Yes
No
Explain
Do you receive disability?
*
Yes
No
Do you receive food stamps?
*
Yes
No
Do you have a valid license?
*
Yes
No
Drivers License Number:
Do you own a vehicle?
*
Yes
No
Make/Model
What is your funding source?
*
Do you have Medicaid?
*
Yes
No
Medicaid Number:
Substance Use History
Do you have a substance abuse problem?
*
Yes
No
When did you last use drugs or alcohol of any kind?
*
What did you use?
*
How much did you use?
*
1st drug of choice:
Route of Administration:
2nd drug of choice:
Route of Administration:
3rd drug of choice:
Route of Administration:
Please provide a brief history of your substance use in your own words. When you started, when you used, how much for how long:
*
Prior substance abuse treatment?
*
Yes
No
Where and when did you go, and did you complete treatment?
*
*
Do you have diabetes?
*
Yes
No
Do you take insulin?
Yes
No
Are you pregnant?
*
Yes
No
Are you receiving Prenatal Care?
Yes
No
Expected Due Date:
Do you have Children?
*
Yes
No
Currently in custody of:
Do you have an open case with Child Protection Services?
Yes
No
Name of CPS Worker:
What was the original cause for your current CPS case:
Names/Ages of children:
Do you have legal custody of your children?
Yes
No
Who has custody?
Legal
Are you currently on probation or parole?
*
Yes
No
Misdemeanor
Felony
*
Probation/Parole Officer:
Phone Number
Have you ever been charged for a violent crime or crime of sexual nature?
*
Yes
No
Please explain
Do you have charges pending or are you awaiting sentencing?
*
Yes
No
*
Who referred you here?
*
{name}
Signature
*
Date and Time
Submit
Should be Empty: