Resident Application

Resident Application

Application for a men's sober living home.
Applicant Information
Legal Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Address

Street Address

CityStateZip Code
Government ID Type
Government ID Number
Requested Move-In Date

MonthDayYear
Date
Referral and Current Living Situation
Referred By
Referral Phone
Please enter a valid phone number.Format: (000) 000-0000.
Referral Email
example@example.com
Current Living Situation

Other
Facility or Program Name
Counselor, Case Manager, or Discharge Planner
Release Date

MonthDayYear
Date
Program Fit
Are you applying voluntarily?
If no, please explain:
Are you willing to live drug and alcohol free?
Are you willing to submit to drug and alcohol testing?
Are you willing to attend weekly house meetings and follow house rules?
Current status
Where?
Are you able to pay the first week's Program Fee of $220 for a shared room or $320 for a private room, $25 Resident Services Fee, and one-time $125 Administration Fee?
If no, are you requesting to apply for financial assistance?
Legal and Safety Screening
Do you currently have any active warrants?
If yes, please explain active warrants.
Are you currently on probation, parole, or court supervision?
If yes, please explain your supervision status.
Are you required to register as a sex offender?
Have you been convicted of arson?
Do you have any pending charges or upcoming court dates?
If yes, please explain pending charges or court dates.
Is there any reason your admission could be an immediate safety concern?
If yes, please explain the safety concern.
Sobriety History
Date of last use

MonthDayYear
Date
Primary substance used

Other
Other substances used

Other
Other substances used or anything else about your substance use that could help us assist you?
Approximate length of substance use
Longest period of sobriety
What helped during your longest period of sobriety?
Prior sober living experience
Prior sober living: where and when?
Prior detox, inpatient, outpatient, or IOP treatment
Treatment history: where and when?
Current recovery activities

Other
Number of recovery activities per week
Sponsor or mentor name

First NameLast Name
Sponsor or mentor phone
Please enter a valid phone number.Format: (000) 000-0000.
Applicant Goals
What are your short-term goals while living in the home?
What goals do you have for building stability?
Acknowledgment
I certify that the information provided in this application is true and complete to the best of my knowledge.
I understand that Orange Door Recovery is a structured sober living home and does not provide clinical treatment, therapy, detoxification services, medical services, or behavioral health services.
I understand that submitting this application does not guarantee acceptance or placement.
I understand that acceptance may depend on safety, program appropriateness, proof of sobriety, ability to comply with house structure, bed availability, and management approval.
I understand that false, incomplete, or misleading information may result in denial of admission or termination of residency if discovered after move-in.
E-signature
Date

MonthDayYear
Date
Should be Empty:

Resident Application

Applicant Information

Referral and Current Living Situation

Program Fit

Legal and Safety Screening

Sobriety History

Applicant Goals

Acknowledgment