Inspire Sober Living Application Form
Please complete the application below.
Full Name
First Name
Last Name
What is your age?
Birth Date
-
Month
-
Day
Year
Date
What is your gender?
Please Select
Male
Female
N/A
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Check the conditions that apply to you or any member of your immediate relatives:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Other
Check the symptoms that you' re currently experiencing:
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Other
Are you currently taking medication(s)?
Yes
No
Please list them.
Do you have any Mental Health diagnoses? Please list your diagnosis.
Do you have any medication allergies?
Yes
No
Not Sure
Do you use any kind of tobacco or have you ever used them?
Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them?
Primary Drug of Choice
Describe your history of having a Substance and/or Alcohol Use Disorder.
Describe your involvement in 12-Step Recovery. Please explain Past attempts to manage your sobriety.
Please list your involvement in the legal system throughout your lifetime. Please ensure to include if you are currently on probation or ankle monitoring, have ever been charged with a violent crime, have a history of a sex crime, or have been charged with Arson.
Identification & Transportation: Do you have a driver's License? Social Security Card? Birth Certificate? State ID? Do you have an operational vehicle?
Are you receiving SSI or other Benefits? Are you currently employed?
Please list two references. Each Reference must include the first and last name, phone number, relationship to you, and years known.
Submit
Should be Empty: