Ok Bluff House New Application (1)

Mens Sober Living House Application

2421 Ok Bluff Circle Plover, WI 54467 Email: okbluff2421@gmail.com

Full Name

Date of Birth

Date

Phone Number

Current Full Address

Are you an Alcoholic or Addict?AlcoholicAddictBoth List drugs you used addictively: Date of Last Drink and/or Use:

List drugs you used addictively

Date of Last Drink andor Use

Date

Have you completed any treatment programs?YesNo If yes, name of facility(s) and completion date(s):

If yes name of facilitys and completion dates

Date

When did you attend your first AA or NA meeting

Are you willing to attend FOUR 12 step meetings each week? Do you have a Sponsor? What does your sobriety mean to you?

Are you willing to attend FOUR 12 step meetings each week

Do you have a Sponsor

What does your sobriety mean to you

Do you have any pending legal charges?YesNo If yes, please describe: Are you currently on probation or parole?Yes No If yes, what state and county? Have you ever been incarcerated?YesNo Do you have any warrants?YesNo Are there any legal obligations that may affect your residency here?YesNo If yes, please describe (e.g., court dates, curfews, upcoming house arrest):

If yes please describe

If yes what state and county

If yes please describe eg court dates curfews upcoming house arrest

Date

Are you currently employed?YesNo If yes, employer name and position:

If yes employer name and position

Do you have a reliable source of income?No Yes

If yes, please describe (e.g., job, benefits, family support):

Are you actively seeking employment or job training?Yes If yes, what steps are you taking?

If yes what steps are you taking

Do you have any physical health conditions?YesNo If yes, please describe: Do you have any mental health diagnoses?YesNo If yes, please describe: Do you have a Primary Care Provider? If yes, list doctor's name and phone number:

If yes please describe

Do you have a Primary Care Provider

No Are you currently taking any prescribed medications?Yes If yes, list medications and prescribing doctor(use separate paper if needed)

If yes list medications and prescribing doctoruse separate paper if needed

Are you currently receiving any medical or therapeutic treatment? If yes, please describe:

If yes please describe

House Expectations & Readiness

Have you ever lived in a sober house?No Yes

If yes provide name location and reason for leaving

No Yes Are you willing to participate in household responsibilities? Are you committed to maintaining sobriety while residing here?No Yes What does accountability mean to you in a shared living environment?

What does accountability mean to you in a shared living environment

Are there any concerns or accommodations youd like to discuss before moving in

If accepted, what is your move-in date? explain:

If the date is in the future, please

If accepted what is your movein date If the date is in the future please explain

Date

Is there anything else youd like us to know about your recovery journey goals etc

I understand that Ok Bluff House:

1. Prohibits all members from using alcohol or illegal drugs 2. Operates democratically 3. Requires weekly payments of $80 for rent and $5 for shared expenses I also understand that residency is based on meeting expectations and my behavior and that I reside as a participant sharing space-not as a tenant with exclusive

rights. I waive any landlord/tenant rights and may be asked to vacate the home if I

violate cardinal rules. By signing or typing my full name below, I affirm that all information provided is true and accurate.

Signature

Date