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*

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.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?
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:
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
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
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
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:
YesNo
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).
YesNo
If yes, please describe where the order is active, the monthly amount, and any outstanding balance (arrears).
Level of Education
No Diploma or GEDHigh School DiplomaGEDSome CollegeCollege GraduateOther
Legal History
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
I have a valid Drivers LicenseI have a state-issued photo IDI have my Social Security CardI do not currently have valid identification
Yes – I have a vehicleNo – I do not have transportation
Employment & Financial Information
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.Format: (000) 000-0000.
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
YesNo, I don't agree
Should be Empty:

Welcome to the Future Promises Foundation, Promise House!

Health Screenings