Bridging The Gap Sober Living Application

Bridging The Gap Sober Living House Application
Full Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Phone Number
Do you have an active drivers license?

YesNo
Are you an Alcoholic?

YesNo
Are you addicted to drugs?

YesNo
How did you hear about us
Date of your last drink?
Date of your last drug use?

MonthDayYear
Date
List drugs you used addictively:
When did you attend your first AA or NA meeting?

MonthDayYear
Date
How many AA/NA meeting do you now attend each week?
Are you employed? If “yes” who is your employer?
Are you getting welfare or other non-job related income?If “yes” what?
If you do not have a job will you get one? If “yes,” what job plans do you have?
What is your monthly income right now? What do you expect your monthly income to be next month?
Do you have move in fee of $425?
Marital Status

SingleMarriedSeperatedDivorced
Do you have a medical doctor? If “yes” list the doctor’s name and phone number:
Do you take prescription drugs?If “yes” list drugs prescribed.
When would you like to move in if approved?
Emergency Contact: Name, Relationship, and Phone Number
Should be Empty:

Bridging The Gap Sober Living House Application