Application for Sober Living
www.redeemedlife.us 423-455-5669
Name
First Name
Last Name
Gender
Female
Male
Date of Birth
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact, Relationship & Phone Number
Probation Officer
Case Worker
AA/NA/Sponsor
Counselor
Martial Status
Children & ages
Prior treatment facility or centers and dates
Criminal Record w/ Dates
Are you a Sex Offender
Yes
No
Any Restraining Orders against you?
Yes
No
Have you ever lived in a Sober Living House before? If yes, please provide details
Do you have a history of violence or aggression towards others? If yes, Please explain
Date of last use of alcohol/drugs
Have you completed any addiction treatment programs or therapies? Please explain
Do you have any medical conditions or mental health diagnoses?
How long have you been using drugs/alcohol
List ALL drugs you have used in the past 2 years
Have you been prescribed any medications in the past 6 months? Please list
Current Employment status
Employer Name
Please share your reasons for applying to live in a sober living house
What specific goals do you hope to achieve during your stay in the sober living house
Are you committed to maintaining sobriety during your stay
Do you have a drivers license?
Yes
No
Do you have a sponsor or support system in place to help you maintain your sobriety? Please list:
Do you have any dietary restrictions or allergies
Yes
No
Do you have any physical or mobility limitations
Yes
No
Is there any other information you would like to share that you believe is important for us to know?
Agreement:
I hereby confirm that the information provided in this questionnaire is accurate and complete to the best of my knowledge. I understand that any false or misleading information could result in my application being denied or my expulsion from the sober living house if I am already placed in a Redeemed Recovery House.
Signature
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