Redwood Recovery Project
Sequoia House Resident Application
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Birthdate
*
-
Month
-
Day
Year
Date
Gender
*
Female
Nonbinary
Transgender
Other
Current Address or Residence
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mark at least one option
*
Currently homeless or living in a shelter
Currently incarcerated
Currently hospitalized
Currently in residential treatment or group home
Living with a family member or friend
Living in own private residence
None of these apply
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Relationship Status
*
Single
Single, in a relationship
Engaged
Married
Divorced
Married, but separated
Other
Spouse/Partner/Significant Other’s name
*
N/A if not applicable
Do you have children?
*
Yes
No
Please list all children’s names and ages.
*
Please list all children, regardless of custody status.
Do you currently have an open CPS case?
*
Yes
No
If you answered yes, please list name of case worker and county.
Please list name of case worker and county involvement.
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Are you currently employed?
*
Yes
No
If you answered yes, please list place of employment and approximate length of employment.
Please list place and length of employment.
Are you currently disabled?
*
Yes
No
Are you receiving SSDI?
*
Yes
No
Are you currently on a civil commitment?
*
Yes
No
If you answered yes, please list name of case worker and county.
Please list name of case worker and county involvement.
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Primary Substance of Use
*
Check substances you have abused:
*
Alcohol
Methamphetamine
Heroin/Fentanyl
Other Opioids
Benzodiazepines
Cocaine/Crack
Marijuana
Hallucinogens
Synthetic Drugs
Other
Sobriety/Clean Date
*
-
Month
-
Day
Year
Date
Are you currently participating in treatment for substance abuse?
*
Yes
No
If you answered yes, please list provider/location.
Please note name of clinic, provider, location, and level of care.
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Do you have a mental health diagnosis?
*
Yes
No
Please list all diagnoses and approximate age of diagnosis.
*
N/A if not applicable
Are you currently working with a psychiatric provider?
*
Yes
No
Please list all psychiatric medications, including dosages and instructions.
*
N/A if not applicable
Please list psychiatric provider/location.
*
N/A if not applicable
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Do you have any physical medical conditions?
*
Yes
No
Please list all diagnoses and associated symptoms.
*
N/A if not applicable
Do you have a primary medical provider?
*
Yes
No
Please list primary medical provider/location.
*
N/A if not applicable
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Do you have pending charges?
*
Yes
No
Please list current charges, county of charges, and next court date.
*
N/A if not applicable
Are you currently on probation or parole?
*
Yes
No
Please list probation/parole officer’s name and county
*
N/A if not applicable
Are you currently enrolled in Treatment Court?
*
Yes
No
If you answered yes, please list coordinator and county
Please list coordinator, county, and level of programming.
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Do you have a vehicle?
*
Yes
No
Do you have a valid driver’s license or are eligible for reinstatement?
*
Yes
No
Are you involved in any recovery support groups?
*
Yes
No
Have you ever lived in a sober living home?
*
Yes
No
I have read and understand the Resident Policies and Procedures. I agree to adhere to the Resident Policies and Procedures for the duration of my stay at Sequoia House.
*
Yes
Submit
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