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
*
Stormborn
Waitlist
Other
What do you identify as?
Please Select
Female
Male
Transgender
Other
What are your pronouns?
Who referred you?
Medical conditions (please list all)
Do you have medicaid?
If yes, please provide your medicaid number.
Coming from Detox, Rehabilitation, Jail, Prison, or IOP?
Please list any medications and dosages you are currently taking.
Do you have any disabilities?
Yes
No
Please list any disabilities:
Do you have difficulty remembering things?
Yes
No
Have you seen a therapist?
Yes
No
Have you been hospitalized for mental illness?
Yes
No
If yes, when, where and which dates?
Describe your history of drug and alcohol use.
List drugs used and last dates used
What is your drug of choice?
Have you ever completed to residential drug treatment?
If yes, when and where and which dates?
Have you ever had seizures?
Yes
No
Will you be interested in attending self-improvement groups?
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
If so, are you able to pay program dues? If no, please provide why.
Have you or are you currently incarcerated?
Please Select
Yes
No
If yes, where and what are release dates (if applicable)?
Have you ever been convicted of drug-related offenses?
Yes
No
If yes, please list charges and dates?
Have you ever been convicted of sex crimes or domestic violence?
Yes
No
Are you currently on probation or parole?
Yes
No
Probation or parole officer's name (if applicable), county and phone number.
Have you ever been convicted of arson?
Do you have any outstanding warrants?
Yes
No
Do you have any upcoming court dates and if so, when?
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
Back
Next
We want to know more about you and help you succeed in life!
Submit Application
List 3 core values:
List 3 goals you would like us to help you achieve:
Why do you believe you will be a good fit for this home?
Should be Empty: