Toomey Recovery Housing Application

TOOMEY RECOVERY HOUSING

Tenant Application
Name

First NameLast Name
E-mail
example@example.com
Phone Number
Please enter a valid phone number.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Civil Status:
Birthday and age
Emergency Contact
Name

First NameLast Name
Relationship
Phone Number
Substance Use and Recovery History
Primary Drug of Choice
Sobriety Date

MonthDayYear
Date
Previous Treatment History (Name of Programs and Dates Attended)
Are you involved with 12 step recovery

YesNo
Do you have a sponsor?
Legal History

Have you ever:
Been convicted of a felony?

YesNo
Describe:
Are you currently on Probation, Parole, Drug Court etc?

YesNo
Describe:
Personal Info
Are you currently employed?
Employer Name
Employer Phone Number
Please enter a valid phone number.
Employer Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your current monthly income?
Do you have any medical conditions?

YesNo
If yes, please explain:
Please list current medications:
Please list the name of your prescribing doctor and their phone number:
Additional information
Do you have any allerigies?

YesNo
Please list allergies:
Reason for seeking sober living and why you feel you would be a good client:
Referral Source

Self ReferralTreatment CenterFamily/FriendOther
If referred to a treatment center, please lprovide their name. If referred by a TRH employee, please provide their name.
I certify that above information is true and complete to the best of my knowledge:

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TOOMEY RECOVERY HOUSING

Emergency Contact

Substance Use and Recovery History

Legal History

Personal Info

Additional information