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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
SECTION 2: REFERRAL INFORMATION

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

Other
Referring Agency/Case Manager Name
Agency Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
SECTION 3: RECOVERY HISTORY

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

MonthDayYear
Date
Are you currently in treatment?
If yes, name of program
Have you completed detox?
Are you currently on MAT (Medication Assisted Treatment)?
If yes, medication
Have you previously lived in sober living?
If yes, where and when
SECTION 4: LEGAL STATUS

Legal background information.
Are you currently on probation or parole?
If yes, officer name and phone number
Do you have any pending charges?
If yes, explain
Are you required to register as a sex offender?
SECTION 5: EMPLOYMENT & FINANCIAL INFORMATION

Tell us about your employment and financial situation.
Employment Status
Employer Name (if applicable)
Weekly Income (USD)
Will a third party be assisting with rent?
If yes, name & relationship
SECTION 6: MEDICAL & MENTAL HEALTH

Share relevant medical or mental health information.
Do you have any diagnosed mental health conditions?
If yes, please explain
Are you currently prescribed medications?
If yes, list medications
Do you have any medical conditions we should be aware of?
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

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

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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

Application Fee

Payment Methods