Sober Living Housing Application
Complete this application to select your preferred house and share your medical, treatment, and substance-use history.
Full Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Select the houses you are interested in
*
Cornerstone
Stormborn
Waitlist
Other
Who referred you?
Medical conditions (please list all)
Insurance information
Withdrawal information (history, symptoms, etc.)
List any medications you are currently taking
Do you have any disabilities?
Yes
No
Do you have difficulty remembering things?
Yes
No
Have you seen a therapist?
Yes
No
Have you been hospitalized for mental illness?
Yes
No
Describe your history of drug and alcohol use
List drugs used and last dates used
What is your drug of choice?
Have you ever had seizures?
Yes
No
Would you be interested in 12-step programs?
Yes
No
Maybe
Do you have children?
Yes
No
How would you rate your family relationships?
1
2
3
4
5
Do you have an eating disorder?
Yes
No
Do you have an issue with gambling?
Yes
No
Are you currently employed?
Yes
No
Have you ever been convicted of drug-related offenses?
Yes
No
Have you ever been convicted of sex crimes or domestic violence?
Yes
No
Are you currently on probation?
Yes
No
Probation officer's name (if applicable)
Do you have any outstanding warrants?
Yes
No
Release dates (if applicable)
Have you had any write-ups or disciplinary actions?
Yes
No
Have you been involved in fighting or altercations?
Yes
No
Do you have any learning disabilities?
Yes
No
Do you have Multiple Sclerosis (MS)?
Yes
No
Were you diagnosed with Fetal Alcohol Syndrome?
Yes
No
Submit Application
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