Living Forward Housing Application
Email
*
example@example.com
Full Name:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Phone Number:
*
Current City & State:
*
Emergency Contact Name:
Emergency Contact Phone:
*
Relationship to Emergency Contact:
*
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Recovery Background
Are you currently sober? (Yes/No)
*
Yes
No
Sobriety Date:
*
-
Month
-
Day
Year
Date
Have you completed treatment? (Yes/No/Currently enrolled)
*
Yes
No
Currently Enrolled
Treatment Center Name:
*
Completion Date:
*
-
Month
-
Day
Year
Date
Are you attending recovery meetings? (AA/NA/Other)
*
Yes
No
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Current Situation
What is your current living situation?
*
Why are you seeking sober living?
*
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Employment
Employment Status (Employed/Seeking/Student/Other):
*
Employed
Seeking
Student
Other
Employer Name:
*
Work Schedule:
*
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Legal Information
Are you on probation or parole? (Yes/No)
*
Yes
No
Officer Name and Phone:
*
Any pending legal charges?
*
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Health
Any medical conditions we should know about?
*
Do you take prescribed medications?
*
Any Allergies?
*
Do you require any special living accommodations for a health related reason?
*
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Personal Statement
What are your recovery goals?
*
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Agreement
I understand Living Forward is a sober living environment and I agree to maintain sobriety while residing in the home.
*
I Agree
Submit
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