A.A.A.A. Application

AMERICANS ALLIED AGAINST ADDICTION

Transitional Housing Application

33650 SCOTCH RUN ST. N. SOLDOTNA, AK 99669

E-mail livecleanloveliferockrecovery@gmail.com

Phone 907-395-7194

First Name

Last Name

M.I.

Today's Date

Date

Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Phone

Format: (000) 000-0000.

Email

example@example.com

Driver's License No.

Social Security No.

Date of Birth

Date

Expected Release Date

Date

Are you a resident of Alaska?

If no, list state

Applicants Gender

Have you ever been convicted of a felony?

If yes, explain

Parole/Probation Officer's Contact Address:

Probation Officer's Name

Address

Phone

Format: (000) 000-0000.

Family Information

Full Name

Of Family Member #1

Relationship

Your Relationship To Family Member #1

Address

Of Family Member #1

Phone

Of Family Member #1Format: (000) 000-0000.

Full Name

Of Family Member #2

Relationship

Your Relationship To Family Member #2

Address

Of Family Member #2

Phone

Of Family Member #2Format: (000) 000-0000.

Are You Married

Interest In Recovery

Select your reason for seeking recovery...

Other

Faith, Religion or Spirituality

Select your background of faith/community past or present

Medical History

Do you have a history of substance abuse?

How long has it been since your last substance abuse?

Other

Substance Abuse History

Rows	Frequency	Amount Per Session	First & Last Date Of Consumption
Alcohol
Cocaine(crack)
Ecstasy
Heroin
Inhalants
Marijuana
Methamphetamines
Prescription Medication
Spice

Other

Rows	Frequency	Amount Per Session	First & Last Date Of Consumption
Other Substances

List any past treatment or programs completed in the past

Do you have any current Medical Conditions?

If yes, please explain

List Of Medications

Rows	Name Of Medication	Reason For Prescription	Dose	Date
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6

Primary Health Care Provider

Name

Location

Phone

Format: (000) 000-0000.

Criminal History

Warrants Current In Alaska?

Upcoming Court Arraignments?

If Yes, Location/Date

Have You Ever Been Convicted Of A Felony?

If You Have Ever Been Convicted Of A Felony Please Explain

Charge Of Sexual Crime?

Employment

Are You Currently Employed?

Are You Physically/Mentally Able To Work Full Time?

If no, list state

Health Issues That Prevent Working Status?

If Yes, Explain:

Are You Willing To Begin Employment?

Your Story

Who Are You?

How Did you End Up Where You Are Now?

What Changes Do You Want To See In Your Life?

What Are Your Goals For Yourself?

We encourage you to use this section to elaborate further:

Americans Allied Against Addiction Drug/Alcohol Screening Agreement

I herby give my consent to be screened for drug and alcohol abuse upon admission to Americans Allied Against Addiction. I understand screening may be requested at random and am willing to comply with house rules and regulations. Testing will be required with the purpose of detecting the absence or presence of: Class A Drugs: (Heroin, Cocaine) Class B Drugs: (Amphetamines, Cannabis, etc Alcohol This may be preformed via urine, hair follicle, or blood sample depending on facility policy. I have the right to re-test upon a positive drug screen if the repeated sample is provided no less then 7 days after results. I understand this house has a Zero Tolerance Policy and violation of policies could result in termination of my residency and treatment plan.

Signature

Printed Name

Date

Zero Tolerance Policy

Please Read & Review The Below Policy

Prohibits drug and alcohol use. Residents who are found with possession, use of, or are under the influence of illicit drugs or alcoholic beverages will be dismissed from the facility.
Unauthorized use of prescription medications is not permitted. This applies to residents actively on
facility premises and off.
Violent behavior or threatening of another person will result in termination of contract
Smoking is not permitted in resident’s room at any time. This policy goes with the use of flammable
items such as: vaping, electronic cigarettes candles, matches, etc.
Possession of weapons such as: Firearms, knives, or any weapon used to inflict injury or death, is
prohibited.
Pornographic images, access, and material of any origin are prohibited from the facility.
Residents are not to have contact from relationships. Physical or emotional connection can be resumed after 6 months. This is for the quality and success of your treatment plan provided within
the facility.
Abuse of any kind will not be tolerated. (Verbal, sexual, physical, cyber, etc.)
Residents must sleep in their assigned beds and rooms.
Harassment of religion, race, sexual orientation, marriage status, mental/physical disability and age will not be tolerated.
Theft will result in termination of residency
Gambling of any kind is not permitted
Damage of property will result in dismissal from house unless accidental.