Promise House Sober Living Application Form

Welcome to the Future Promises Foundation, Promise House!

Promise House provides structured housing designed to support men who are working toward stability through recovery, reentry, and personal growth.

There will be a Promise House Program Agreement provided upon application approval. Acceptance of these terms is will be required.

Preferred Move-In or Transition Date to Promise House

Date

Name:

First NameLast Name

Date of Birth

Date

Social Security #

no dash's please

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

E-mail Address:

example@example.com

Do you have a current address?

Current Address or residence:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What is this residence?

Treatment/parents home/ friend/hotel ect?

How were you referred to us?

Addiction History

How do you currently identify in relation to your substance use history?

Choose one

Other:

Are you currently involved in any recovery support meetings or groups?(Select all that apply — we welcome all recovery paths.)

Other

Other (Please share):

What is your most recent sobriety or clean date?

Date

Which substances have played a significant role in your use or recovery journey?

Other (Please Specify)

Treatment and Mental Health History

Have you recently received treatment for substance use or mental health?

Note: If you have not received treatment recently, you're still welcome to apply. We meet individuals where they are in their journey.

Mental Health

Have you ever been diagnosed with a mental health condition?

If yes, please list the diagnosis, the year it was made, and who made it (if known).

Example: PTSD – Diagnosed in 2020 by Dr. Smith at Community Counseling Center

Are you currently prescribed medications for any mental health conditions?

If yes, please list each medication, dosage (mg), and how often you take it.

Example: Zoloft – 100mg – Once daily in the morning

Prescribing Provider (Name & Phone):

Name and phone number (Example: Dr. Jane Doe – (302) 555-1234)

Physical Health & Medical Conditions

Please list any physical or medical conditions we should be aware of:

Example: High blood pressure, migraines, diabetes

Do you have any conditions that limit your mobility or physical activity?

Are you currently prescribed any other medications?

If yes, list medication names, dosages, and schedule. If none, write "N/A."

Example: Lisinopril – 10mg – once daily

You may upload a current medication list here (optional).

Hep C?

HIV/AIDs?

Relationships & Family

Relationship status

Are you currently in a romantic relationship or have you ended one in the last year? Please explain briefly:

This may help us understand your current support system or emotional state.

Partner / Spouse Information

First NameLast Name

Please list the name(s) and age(s) of your children (If applicable).

Do you currently have a child support order?

If yes, please describe where the order is active, the monthly amount, and any outstanding balance (arrears).

Level of Education

Highest Level of Education Completed

Legal History

Legal Background (Check all that apply):

If you checked any of the above, please briefly explain the circumstances.

Be thorough in your explanation.

Identification and Transportation

Check which apply

Do you have access to reliable transportation?

Employment & Financial Information

Are you currently employed

Employers Name & Address

Name

Street Address

CityState / Province

Postal / Zip Code

Immediate Supervisors Name

If none type N/A

Employers Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Do you currently receive SSI, SSDI, or other benefits?

If you are not currently employable, please briefly explain why.

Upload any supporting documents you'd like us to review (optional):

Please sign below to confirm that all information provided is accurate to the best of your knowledge.Signature

Date of Signature

Date

Have you reviewed and agreed to the Promise House Program Agreement?

Welcome to the Future Promises Foundation, Promise House!

Health Screenings