Level 1 Housing Application

Recovery Housing - Level 1 Application
How did you hear about us?*
What is your available move-in date?*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Best Phone Number to Contact you:*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Where are you currently staying?*

Recovery HousingHome (owned/rented)Friend's HouseHomeless Shelter
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Address County:*
Gender*
Marital Satus*
SSN:*
Do you have a photo ID?*

YesNo
Are you able to walk stairs?*

YesNo
Are you currently employed?*

YesNo
Employment Status*

Full TimePart TimePRN/Seasonal
Recovery History
Primary substance used:*
Sobriety Date:*

MonthDayYear
Date
Have you completed in-patient treatment in the last 2 years?*

YesNo
PREVIOUS Treatment Center Name:*
PREVIOUS Treatment Admission Date:*

MonthDayYear
Date
Do you currently have recovery support services?*

YesNo
Which services are you involved in?*

Peer Support/Recovery CoachIOP/PHPCounselingPsychiatry
Who provides out-patient services? (i.e. Ohio Guidestone, Alternative Paths, etc)*
Have you ever or do you currently live in recovery housing/sober living?*

YesNo
Previous Recovery Housing (add all)*
Please list medical history: *
Do you take medications?*

YesNo
Medication List*
Are you on any MAT substances?*

SuboxoneSublocadeVivitrolOtherNone
Criminal Justice Involement
Please note, failure to disclose full criminal history or pending warrants will result in termination from the recovery housing program.
Are you a registered sex offender?*

YesNo
Do you have any outstanding warrants?*

YesNo
Please list active warrants and location:*
Do you have any felony convictions?*

YesNo
Please list all felony convictions:*
Are you on probation?*

YesNo
Probation officer name:*
Probation county:*
Do you have any pending jail time or upcoming sentencing?*

YesNo
Please explain upcoming sentencing/jail time:*
Can you pass a drug/alcohol test?*

YesNo
General Notes:
AUTHORIZATION FOR BACKGROUND CHECK
By signing below, I authorize Hope Recovery Community to conduct a background check at their discretion for any reason that they deem said background check necessary or helpful to their conducting business.

By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.

Once your form is submitted we will call you to conduct a phone interview.
Signature*
Should be Empty:

Recovery Housing - Level 1 Application

Recovery History

Criminal Justice Involement