Just Breathe Sober Living Resident Application

Just Breathe Sober Living Resident Application

Apply to become a resident. Please complete all sections accurately to begin the intake process.
SECTION 1: APPLICANT INFORMATION

Please provide your personal and emergency contact information.
Full Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number (Last 4 digits)*
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Current Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name*

First NameLast Name
Emergency Contact Relationship*
Emergency Contact Phone*
Please enter a valid phone number.
SECTION 2: REFERRAL INFORMATION

Tell us how you heard about Just Breathe Sober Living.
How did you hear about Just Breathe Sober Living?*

Treatment CenterRecovery WorksProbation/ParoleSelf-ReferralFamily/FriendOther
Referring Agency/Case Manager Name
Agency Phone Number
Please enter a valid phone number.
SECTION 3: RECOVERY HISTORY

Share your recovery background.
Primary Substance(s) Used*
Date of Last Use*

MonthDayYear
Date
Are you currently in treatment?*

YesNo
If yes, name of program
Have you completed detox?*

YesNo
Are you currently on MAT (Medication Assisted Treatment)?*

YesNo
If yes, medication
Have you previously lived in sober living?*

YesNo
If yes, where and when
SECTION 4: LEGAL STATUS

Legal background information.
Are you currently on probation or parole?*

YesNo
If yes, officer name and phone number
Do you have any pending charges?*

YesNo
If yes, explain
Are you required to register as a sex offender?*

YesNo
SECTION 5: EMPLOYMENT & FINANCIAL INFORMATION

Tell us about your employment and financial situation.
Employment Status*

Full-TimePart-TimeUnemployedDisabilityRecovery Works
Employer Name (if applicable)
Weekly Income (USD)
Will a third party be assisting with rent?*

YesNo
If yes, name & relationship
SECTION 6: MEDICAL & MENTAL HEALTH

Share relevant medical or mental health information.
Do you have any diagnosed mental health conditions?*

YesNo
If yes, please explain
Are you currently prescribed medications?*

YesNo
If yes, list medications
Do you have any medical conditions we should be aware of?*

YesNo
If yes, explain
SECTION 7: HOUSE RULE AGREEMENT

Please read and agree to the house rules.
SECTION 8: CONSENT & RELEASE

Consent to verification and background screening.
Applicant Signature*
Date*

MonthDayYear
Date
Application Fee
prevnext( X )
Application Fee
$100.00 Quantity

Total

$0.00
Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info
Should be Empty:

Just Breathe Sober Living Resident Application

SECTION 1: APPLICANT INFORMATION

SECTION 2: REFERRAL INFORMATION

SECTION 3: RECOVERY HISTORY

SECTION 4: LEGAL STATUS

SECTION 5: EMPLOYMENT & FINANCIAL INFORMATION

SECTION 6: MEDICAL & MENTAL HEALTH

SECTION 7: HOUSE RULE AGREEMENT

SECTION 8: CONSENT & RELEASE