Toomey Recovery Housing Application
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday and Age
Emergency Contact
Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Substance Use and Recovery History
Primary Drug of Choice
Sobriety Date
-
Month
-
Day
Year
Date
Previous Treatment History (Name of Programs and Dates Attended)
Involved in 12 Step Recovery Meetings?
Please Select
Yes
No
If yes, describe. Do you have a sponsor or have worked any steps?
Employment History
Currently Employed?
Please Select
Yes
No
Employer and Job Title
Monthly Income
Legal History
Have you ever been convicted of a crime? If so list convictions and dates
Are you currently on Probation, Parole, Drug Court etc?
Please Select
Yes
No
If yes, please give details
Name of Parole Officer or Primary point of contact and contact info
Medical
Current Medical Conditions
Current medications (name, dosage, and frequency)
Allergies
Primary Care Physician (name and phone number)
Reason for Seeking Sober Living
Please use the following space to discuss why you are interested in Toomey Recovery Housing and why you feel you would be a good client
Referral Source
Self Referral
Treatment Center
Treatment Center
Family/Friend
Other
If referred by a treatment center, put their name. If referred by a client of TRH please put their name.
I certify that above information is true and complete to the best of my knowledge
Signature
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