Charlie's House Sober Living Application

Date

MonthDayYear
Date
First Name
Middle Initial
Last Name
Current Address
City
State
Zip
Date of Birth (DOB)

MonthDayYear
Date
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
When would you like to begin sober living?
Desired Start Date

MonthDayYear
Date
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about Charlie's House?
Race

Other
If Other, specify Race
Gender

Other
If Other, specify Gender
Housing Status

Other
If Other, specify Housing Status
Employment Status

Other
If Other, specify Employment Status
Estimated Annual Income
Are you currently in treatment?
Treatment Facility
Anticipated Discharge Date

MonthDayYear
Date
Counselor’s Name
Counselor Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you a Drug Court participant?
If yes, what county?
Drug Court Case Manager Name
Drug Court Case Manager Phone
Please enter a valid phone number.Format: (000) 000-0000.
Are you on a settlement agreement or commitment?
Case Worker Name
Case Worker Phone
Please enter a valid phone number.Format: (000) 000-0000.
Are you currently on probation?
Probation Agent Name
Probation Agent Phone
Please enter a valid phone number.Format: (000) 000-0000.
Length of time remaining on probation
Have you ever been incarcerated?
If yes, list all dates/locations of incarceration
Do you have any pending legal charges?
If yes, list all pending charges
Do you have any felony and/or misdemeanor convictions?
If yes, list all convictions
Have you ever been convicted of a sex offense?
If yes, list specific offenses
Do you have any children?
Have you ever had a non-fatal overdose?
Does addiction/alcoholism run in your family?
How many treatments have you been to?
Have you ever been diagnosed with a mental illness?
If yes, list mental illnesses
Current Medications
Do you have any medical conditions?
If yes, list medical conditions
Sobriety Date

MonthDayYear
Date
Drug(s) of Choice
12-step Program Affiliation

Other
If Other, specify 12-step Program
Do you have a sponsor?
Sponsor Name
Are you currently employed?
Employer
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Rate of Pay
Hours per Week
If not employed, how do you plan to pay for intake fees and program fees?
Property Pickup Contact Name
Property Pickup Contact Relationship
Property Pickup Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
I agree to remain clean and sober at all times
Initial
I agree to pay program fees in advance
Initial
I agree to keep Charlie's House free from alcohol and drugs
Initial
I agree to enter a behavioral contract and abide by the terms
Applicant Signature
Signature Date

MonthDayYear
Date
Should be Empty: