Serenity House Sober Living Application Form

Welcome to the Future Promises Foundation, Promise House!

Thank you for your interest in The Promise House, a collaborative sober living program by Future Promises Foundation and Serenity Health & Recovery. We are committed to supporting your journey to stability, healing, and independence.

Before you begin, please make sure you've reviewed our Promise House Program Agreement. Acceptance of these terms is required to proceed.
Have you reviewed and agreed to the Promise House Program Agreement?*

YesNo, I don't agree
Preferred Move-In or Transition Date to Promise House*

MonthDayYear
Date
Name:*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security #*
no dash's please
Phone Number*
Please enter a valid phone number.
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?*

Treatment ProviderFriendRecovery ResourceFacebookInternet SearchCurrent or Past ResidentPoster/FlyerOther
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.)*

I currently attend AA (Alcoholics Anonymous) meetingsI currently attend NA (Narcotics Anonymous) meetingsI attend both AA and NAI attend another type of recovery support group (e.g., SMART Recovery, church-based, peer-led)I plan to start attending once I complete treatmentI’ve attended meetings in the past but didn’t find them helpfulI’ve never attended any recovery support groupsOther
Other (Please share):
What is your most recent sobriety or clean date?*

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

AlcoholOpioids (heroin, prescription opioids, fentanyl)CocaineMethamphetamine (Crystal)MarijuanaPrescription medications (used outside prescription)Synthetic/substitutes (e.g., K2, bath salts, xylazine)HallucinogensBarbiturates & sedativesOther
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?*

YesNo
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?*

YesNo
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).

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Health Screenings

Have you been tested for:
Hep C?*

YesNo
HIV/AIDs?*

YesNo
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?*

YesNo
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*

No Diploma or GEDHigh School DiplomaGEDSome CollegeCollege GraduateOther
Legal History
Legal Background (Check all that apply):*

No criminal historyCurrently on probationCharged with a violent crimeConvicted or charged with arsonConvicted of a sex offenseOn electronic monitoring (ankle bracelet)Other
If you checked any of the above, please briefly explain the circumstances.
Be thorough in your explanation.
Identification and Transportation
Check which apply*

I have a valid Drivers LicenseI have a state-issued photo IDI have my Social Security CardI do not currently have valid identification
Do you have access to reliable transportation?*

Yes – I have a vehicleNo – I do not have transportation
Employment & Financial Information
Are you currently employed*

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

YesNo
If you are not currently employable, please briefly explain why.
Upload any supporting documents you'd like us to review (optional):

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

Clear
Date of Signature*

MonthDayYear
Date
Should be Empty:

Welcome to the Future Promises Foundation, Promise House!

Health Screenings