Sober Living Application Form

Sober Living Application

Fill the form below accurately.
Before you begin:

Be certain that you have read and agreed to our Sober Living Agreement Click on the link to review this now. This is a MUST !!!

You will need the following items
- A list of all
  - medications, names, milligrams & frequency
  - Doctors names and contacts
  - current treatment information
  - Probation information including phone #'s
I have read the Sober Living Agreement and agree to all the policies and agreements *

Yes No I don't agree
Provide as much information as possible. Incomplete applications will not be considered. Let your efforts in this reflect your desire for recovery.
Name: *

First Name Last Name
Birth Date *

Month Day Year
Social Security # *
no dash's please
Phone Number: *

Area Code Phone Number
E-mail Address:
Current Address or residence: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
What is this residence? *
Treatment/parents home/ friend/hotel ect?
Previous Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How were you referred to us? *

Treatment Provider Friend Recovery Resource Facebook Internet Search Current or Past Resident Other (please specify)
Others:
Addiction History
Do you consider yourself *
Choose one
Primary Drug Of Choice *
Describe your history with addiction: *

In detail describe when you began experiencing problems with control and and any progression that has occurred with your use of drugs or alcohol. 0/0
Periods of sobriety / Clean time *

Describe any periods you have been able to remain clean. What did you do to achieve this / maintain this? 0/0
Involvement in 12 Step Recovery- Check all that Apply *

I'm currently attending AA meetings I'm currently attending NA Meetings I attend both AA and NA Meetings I would attend meetings but cannot at this time because of treatment restrictions I'm anxious to make meetings when I finish my treatment commitment I have attended meetings in the past but do not find it helpful I have never attended 12 step meetings
Sobriety / Clean Date *

Month Day Year
Date
Sponsors Name and Phone
Leave blank if you do not have one
Check drugs abused *

Alcohol Heroine Methamphetamine (Crystal) LSD / Hallucinogens Barbiturates Cocaine Marijuana Bath Salts K2 or Synthetics
Treatment and Mental Health History
Are you currently or recently received Treatment for your Addiction(s) *
What is your release date or date that you would like to enter Sober Living? *

Month Day Year
Date
Treatment Provider Information

Name

Address

City State

Zip Code
Treatment Provider Phone

Area Code Phone Number
Case Manager Email *
example@example.com
Case Manager or Discharge Coordinator(s) Name *
Phone Number

Area Code Phone Number
Primary Therapist Info

First Name Last Name
Therapist Phone Number

Area Code Phone Number
* Please be certain to have a release of information filed so that I may inquire of your treatment team.
Mental Health
Do you have any Mental Health Diagnosis *

Yes No
If you answered yes to the previous question list your diagnosis. Include when and by whom this diagnosis was made.
This information is vital to your application. Please be thorough and accurate.
Are you prescribed any medications for a mental health condition *

Yes No
List all medications prescribed INCLUDING DOSAGE AND TIMES DAILY *
* This information must be correct
Prescribing Doctor
Name and phone number
Medical Conditions
List all Medical Conditions *
Blood pressure, headaches, ect
Do you have any conditions that limit your mobility *
Foot , back, leg problems. COPD ect
Prescribed Medications List all names, dosages (milligrams) and times daily *
If none- write NONE or N/A
If you have a list of current medications/prescriptions you may upload them here.

Browse Files

Cancel of
Have you been tested for Hep C? *

Yes No
Have you been tested for AIDs? *

Yes No
Relationships
Marital Status *

Single Married Common Law Partner Divorced
Are you currently involved in a romantic relationship or have you ended a relationship in the last year? *
EXPLAIN IN DETAIL
Relationship status *
Partner / Spouse Information

First Name Last Name
Partner / Spouse

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Name and Age of Minor Children
Name and Age Of Adult Children
Custodial Parent(s) Contact Information
Name - Address Phone number
Do you have a child support order (s) *

Yes No
If yes to the previous question state in detail where the order exist, the amount of the monthly order and any amount in the rears (owed).
Level of Education
Education

No Diploma or GED High School Diploma GED Some College College Graduate
Legal Information
Criminal History Check all that apply from your lifetime *

I have no criminal history I am currently on Probation I have been charged with a Violent Crime I have committed or have been charged with Arson I have a Sex Crime conviction I'm on Ankle Monitoring
If you have answered yes to any of the above, state in detail the circumstances of the offense(s)
Be thorough in your explanation.
County / Municipality of Probation
Probation Officer Name

First Name Last Name
Probation Officer Phone

Area Code Phone Number
Identification
Check which apply *

I have a valid Drivers License I do Not Have a valid Drivers License I have my Social Security Card I have a State Id I Do NOT have an ID
Do you have a operational vehicle

Yes I have a car No, I have no vehicle
Employment
WORK Experience (What do you do for employment. Trades, Degrees, Special skills and Training) *
List all various fields/jobs you have experience in
Are you currently employed *

Yes No
Employers Name & Address

Name

Street Address

City State / Province

Postal / Zip Code
Employers Name and Phone *
If none type N/A
References

Please list two (2) references that are familiar with your life and current situation.
Reference 1
Name: *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
Years Known: *
Relationship to You
(friend/ Employer/ family member)
Reference 2
Name: *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
Years Known: *
Relationship to You
(friend/ Employer/ family member)
Upload any additional documents
Signature *

Clear
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