Sacred House of Recovery & Care Wisconsin Lodger Application Form
***only accepting male applicants at this time***
Lodger Details:
I have reviewed the Policy/Procedures document and Phase System document *
*
Yes
Full Name
*
First Name
Last Name
Phone Number
*
E-mail
*
example@example.com
Birthdate (Month, Date, Year)
*
-
Month
-
Day
Year
Date
How did you hear about us?
*
Please Select
Internet
Flier
Other
Secondary Contact (Optional)
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Gender
*
Male
Female
Prefer not to say
Preferred Move in Date? (Month, Date, Year)
*
-
Month
-
Day
Year
Date
Have you previously resided in a sober living residence?
*
Yes
No
If answered yes, please list year of previous sober living residence stay.
*
-
Month
-
Day
Year
Date
If answered yes to previous question, please list name of previous sober living residence.
*
If answered yes, what was the reasoning for leaving your previous sober living residence?
*
Employment Details
Are you currently employed?
*
Yes
No
Current Employer
*
Length of Employment
*
Monthly Salary
*
Other Key Information
Are you an alcoholic?
*
Yes
No
Date of last drink?
*
-
Month
-
Day
Year
Date
Are you addicted to drugs?
*
Yes
No
Date of last drug use?
*
-
Month
-
Day
Year
Date
Please list drugs you have used addictively:
*
How many 12 step or other support group meetings do you attend per week?
*
Do you have any prior convictions for any violent or sexual crimes?
*
Yes
No
If answered yes to previous question, please explain.
Do you have pending charges for any violent or sexual crimes?
*
Yes
No
If answered yes to previous question, please explain.
Have you ever been to a treatment facility for alcohol/drug addiction?
*
Yes
No
If "yes" list the dates of treatment:
*
Do you take prescription drugs?
*
Yes
No
If "yes" list medications and reasons they are prescribed:
Please list any medical information that would be needed in an emergency:
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Any other relevant information or notes that you want to include? If not, put N/A
*
By submitting this application you agree: 1) The information provided herein is complete and accurate. Providing incomplete and/or false information could result in the rejection of the application. 2) Submission of this application does not guarantee a room lease, which is reserved only upon signing of a completed lease agreement by all parties. Additionally, no other agreements, either written or oral, are binding on applicant, owner or owner's agents until the completed lease agreement is signed by all parties. 3) Additional information may be required in order to process your application. Our management team will contact you upon receipt of this online application to obtain any additional information necessary to complete the processing of your application.
Confirm
*
I agree
Signature
Please verify that you are human
*
Submit
Submit
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