Sober Living Application
Before you begin, you must have read our Rules and Regulations. Provide as much information as possible. Let your efforts in this reflect your desire for recovery.
Applicant Details
I have read the Spokane Women's Sober Living Rules and Regulations and will agree to them if I am accepted.
*
Yes, I agree
No, I do not agree
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Sobriety Date
*
-
Month
-
Day
Year
Date
Race/Ethnicity
*
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What type of living situation is this?
*
Home/treatment/jail/friends house/etc
E-mail
*
example@example.com
Sex
*
Gender
*
Pronouns
*
How will you be paying your rent?
*
Self pay, funding agency, or do you need rental assistance?
Do you have a significant other?
*
Do you understand the move in deposit/administration fee is $300 and monthly rent is $700?
*
Yes
No
In order to "hold your bed" prior to move in, 50% of the move in cost is due. $500. This is non-refundable if you no-show for move-in.
*
I understand
Emergency Contacts
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Addiction History
Do you consider yourself
*
Please Select
Alcoholic
Drug Dependent/Addict
Alcoholic/Addict
Drug of Choice
*
Describe your history with Addiction
*
Involvement in Recovery
*
I'm currently attending AA meetings
I'm currently attending NA meetings
I attend both AA and NA Meetings
I will attend meetings but cannot at this time because of treatment restrictions
I have attended meetings in the past but do not find them helpful
I have never attended AA
I attend a different recovery program
Other
Sponsor's Name
Have you ever lived in an Oxford house or sober living environment before?
*
Treatment and Mental Health History
Are you currently or recently received treatment for your addiction?
*
What is your release date or date that you would like to enter sober living?
*
-
Month
-
Day
Year
Date
Treatment Provider Info
*
Do you have any Mental Health Diagnosis?
*
Yes
No
If you answered yes to the previous question, list your diagnosis.
This information is vital to your application. Please be thorough.
Are you prescribed any medications for a mental health condition?
*
Yes
No
If you answered yes to the previous question, list all medications prescribed as well as dosing and times daily.
*
Are you continuing in outpatient treatment of some form? Please describe and include contact info.
*
Medical Conditions
List all medical conditions
*
List all allergies:
*
Do you have any conditions that limit your mobility?
*
List any additional medications prescribed and their dosages and times daily.
*
If you are not employable, please give an explanation here.
*
Do you have any physical limitations? Can't do stairs, etc?
*
Legal Information
Criminal History (check all that apply from your lifetime)
*
I have no criminal history
I am currently on Probation
I have committed or been charged with a violent crime
I have committed or been charged with arson
I have committed or been charged with a sex crime conviction
I am on ankle monitoring
I have a criminal history but I am not currently on probation
Other
If you answered yes to any of the above, state in detail the circumstances of the offense(s).
*
Have you had any disciplinary actions or write ups while incarcerated?
*
City/County/State of Probation
*
Probation Officer
*
First Name
Last Name
Probation Officer Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
DOC Number
*
Identification and Transportation
Check which apply
*
I have a valid drivers license
I do not have a valid drivers license
Do you have an operational vehicle?
*
Yes, I have an operational vehicle that I will be brining to the residence
Yes, I have a car but I will not be bringing it
No, I do not have a car
I understand SWSL does not provide transportation.
*
I understand.
No, I do not understand.
Employment
Work Experience(what do you do for employment? Trades, degrees, special skills, trainings, etc)
*
Are you currently employed?
*
Yes
No
What is your work schedule?
*
Daytime
Evening
Overnight
My schedule varies
Not employed
If you are not currently employed, will you be seeking employment?
*
Yes
No
If you do not plan on seeking employment, explain why:
*
Recovery
What do you hope to accomplish by living in Sober Living?
*
Do you have a certain timeline you'd like to stay in Sober Living? (example: plan to stay 6 months until I can get an apartment, etc)
*
What are your goals in sobriety?
*
Do you have a support system in the Spokane area? Sober friends, family, etc? If not, do you plan to build a healthy support system?
*
Thank you for your application. Submitting this application does not guarantee you will be accepted. Please sign below.
Signature
Continue
Continue
Should be Empty: