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*

YesNo 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 NameLast Name
Birth Date*

MonthDayYear
Social Security #*
no dash's please
Phone Number:*

Area CodePhone Number
E-mail Address:
Current Address or residence:*

Street Address

Street Address Line 2

CityState / Province

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

Street Address

Street Address Line 2

CityState / Province

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

Treatment ProviderFriendRecovery ResourceFacebookInternet SearchCurrent or Past ResidentOther (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 meetingsI'm currently attending NA MeetingsI attend both AA and NA MeetingsI would attend meetings but cannot at this time because of treatment restrictionsI'm anxious to make meetings when I finish my treatment commitmentI have attended meetings in the past but do not find it helpfulI have never attended 12 step meetingsOther
Sobriety / Clean Date*

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

AlcoholHeroineMethamphetamine (Crystal)LSD / HallucinogensBarbituratesCocaineMarijuanaBath SaltsK2 or SyntheticsOther
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?*

MonthDayYear
Date
Treatment Provider Information

Name

Address

CityState

Zip Code
Treatment Provider Phone

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

Area CodePhone Number
Primary Therapist Info

First NameLast Name
Therapist Phone Number

Area CodePhone 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*

YesNo
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*

YesNo
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.

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Have you been tested for Hep C?*

YesNo
Have you been tested for AIDs?*

YesNo
Relationships
Marital Status*

SingleMarriedCommon Law PartnerDivorcedOther
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 NameLast Name
Partner / Spouse

Street Address

Street Address Line 2

CityState / 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)*

YesNo
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 GEDHigh School DiplomaGEDSome CollegeCollege GraduateOther
Legal Information
Criminal History Check all that apply from your lifetime*

I have no criminal historyI am currently on ProbationI have been charged with a Violent CrimeI have committed or have been charged with ArsonI have a Sex Crime convictionI'm on Ankle MonitoringOther
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 NameLast Name
Probation Officer Phone

Area CodePhone Number
Identification and Transportation
Check which apply*

I have a valid Drivers LicenseI do Not Have a valid Drivers LicenseI have my Social Security CardI have a State IdI Do NOT have an ID
Do you have a operational vehicle

Yes I have a carNo, 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*

YesNo
Employers Name & Address

Name

Street Address

CityState / Province

Postal / Zip Code
Employers Name and Phone*
If none type N/A
Are you Receiving SSI or other benifits?

YesNo
If you are not employable please give an explanation here.
References

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

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

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

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

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

Upload a File

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