Application Form for Drew's Sober Living

Application Form for Drew's Sober Living

Please fill out the form below to apply for Drew's Sober Living.
Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
What is your birth date?

MonthDayYear
Date
What location are you looking to move into?*

Chittim House - North San AntonioEvergreen House - Central San AntonioChapel house - New BraunfelsI am open to any!
What date do you need to move in?

MonthDayYear
Date
Tell us about yourself and why you are seeking sober living.*
Have you lived in a sober living before?*

YesNo
Are you currently taking any medications?*

YesNo
Can you pass a drug and alcohol test?*

YesNoMaybeI am prescribed medication that will cause me to fail.
Are you currently employed?*

YesNoIm working on itI am unable to work
Do you have a valid driver's license?*

YesNoIm working on itI am unable to drive
Do you own a vehicle?*

YesNoIm working on itI am unable to drive
Have you been to an inpatient treatment for substance abuse or mental health before. If so, when and where was the last time you went in treatment.*
When was the last time you used drugs or alcohol?*
Are you currently participating in a recovery program?*

YesNo
Do you have a 12 step sponsor?*

YesNoOther
What are your recovery goals?*
Do you have a source of income to pay your program fees?*

YesNoNot Yet
Are you able to make the initial deposit and pay your program fees on time?*

YesNoNot Yet
Do you have any medical conditions or disabilities we should be aware of?
Do you have a primary care doctor?*

YesNo
Do you have a therapist?*

YesNo
Do you have health insurance?*

YesNo
Do you have any pending legal matters?*

YesNo
Are you on probation or parole?*

NoProbationParole
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Is there anything else we need to know about you, or anything you would like to share with us?
What size shirt do you wear?*

SmallMediumLargeXL2XL3XLOther
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