Clone of Freedom House Application

Name*

First NameLast Name

Birth Date*

Date

Date Applying (Today)

Date

Email Address*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Other Phone (optional)

Please enter a valid phone number.Format: (000) 000-0000.

Address (optional)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Relationship Status

SingleMarriedDivorcedWidowed

Gender*

MaleFemale

Are you currently enrolled in a treatment or support program?

YesNo

If yes, which program?

Caseworker Name

First NameLast Name

Caseworker Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Are you in recovery?

YesNo

Date of last use*

Date

Are you currently participating in AA or NA meetings?

YesNo

How will you pay program fees?*

If Other, please explain.

Have you ever been convicted of a felony?

YesNo

If Yes, What is the nature of conviction?

Are you on parole or probation?

YesNo

If Yes, Name of Probation or Parole Officer

First NameLast Name

Probation or Parole Officer Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Are you legally mandated to live in a sober house?

YesNo

If yes, by whom?

Do you own a car?

YesNo

Do you currently take any prescription or over-the-counter medications?

YesNo

If Yes, are any of your medications controlled substances (e.g. benzodiazepines, stimulants, narcotics)?

YesNo

Please list all current medications below.

Upload Government-Issued Photo ID*

Applicant Statement (Please read before signing)

I hereby authorize Freedom House Sober Living and its designated agents to conduct a review of my background including income, housing, treatment, criminal history, or any other public records. I authorize any individual, company, or public agency to release any information, verbal or written, pertaining to me, to Freedom House Sober Living or its agents. I will allow a photocopy or scanned image of this authorization to be as valid as the original. I understand that Freedom House Sober Living is a structured recovery program and not a rental property. I am applying for participation in this community-based program and, if accepted, I will be granted a revocable license to occupy a program bed as long as I remain in compliance with the rules, policies, and expectations set forth in the Freedom House Participant Handbook. I acknowledge that this is not a landlord-tenant arrangement, and that my occupancy is contingent upon ongoing participation in the recovery program. Freedom House Sober Living reserves the right to discharge any participant who violates program rules, without the need for formal eviction proceedings.

Signature*

Date*

Date

Freedom House Email

Program Participant Application - Freedom House Sober Living