Santa Rosa Sober Living Application
Please complete this application to be considered for residence in our sober living home.
Applicant Information
Tell us about yourself.
Full Legal Name
*
First Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name
*
Emergency Contact Relationship
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you seeking placement in a male sober living environment?
*
Yes
No
Admission Readiness & Fees
Information about your move-in and financial readiness.
Preferred Move-In Date
*
-
Month
-
Day
Year
Date
Are you able to pay the required fees at admission? (Administrative Fee: $300 one-time, applied as a credit toward first month and used to hold the bed; Membership Fee: $800 per month)
*
Yes
No
Legal History
Tell us about your legal background.
Do you have any outstanding warrants, unresolved citations, or child support obligations?
*
Yes
No
If yes, please explain
Are you currently on probation, parole, or court supervision?
*
Yes
No
If yes, please explain
Do you have any upcoming court dates?
*
Yes
No
If yes, please list dates
Treatment & Recovery History
Your treatment and recovery experience.
Have you completed a minimum 30-day detox or treatment program?
*
Yes
No
If yes, facility name and completion date
Sobriety Date (most recent)
*
-
Month
-
Day
Year
Date
Substances you are in recovery from
*
Are you currently participating in outpatient treatment, IOP, or counseling?
*
Yes
No
Sober Living History
Your previous sober living experience.
How many sober living homes have you previously lived in?
*
None
1
2
3 or more
If applicable, list locations and approximate dates
Medications & Mental Health
Your current medications and mental health status.
Are you currently prescribed any medications?
*
Yes
No
If yes, list medications
Are medications taken as prescribed?
*
Yes
No
Do you have any diagnosed mental health conditions?
*
Yes
No
If yes, list diagnoses
Are you currently receiving mental health treatment?
*
Yes
No
Accountability & Structure
Your willingness to comply with house structure.
Are you willing to participate in a 12-Step or alternative recovery program for your first 90 days?
*
Yes
No
Are you willing to complete a toxicology screening at move-in?
*
Yes
No
Are you willing to comply with random substance screenings?
*
Yes
No
Employment / Education
Tell us about your current work, school, or activity status.
Current status
*
Employed
School
Structured activity
Not currently
If not active, are you willing to secure employment, school, or approved activity within 30 days?
Yes
No
Applicant Acknowledgment
Please read and confirm.
Submit Application
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