Resident Application Intake Form

Applicant First Name *

Applicant Last Name *

Applicant Email

Applicant Phone

Sex *

Date of Birth *

Street Address

City

State

Postal Code

Marital Status

Driver's License # or ID #

If suspended or revoked, enter N/A

Last 4 of Social Security # *

Used for identity verification only. Never share your full Social Security number.

Sobriety Date

Addiction History (please list all substances used)

Do you have a Case Manager? *

YesNo

Case Manager Name

Case Manager Email

Case Manager Phone #

Have you ever been in a treatment program? *

YesNo

Most recent treatment start date

Length of stay

Did you complete the program?

YesNo

Treatment center name & address

If currently in a treatment center, discharge date

If accepted, desired move-in date

If accepted, how long do you envision living with us?

Have you ever lived in a recovery home? *

YesNo

If so, recovery home name & address

Reason for leaving

Are you currently attending 12-step meetings? *

YesNo

If yes, how many per week?

Education *

Why do you want to live in a sober house?

How did you hear about us?

What other information should we consider when reviewing your application?

Emergency Contact Name *

Relationship

Phone # *

Address

Are you capable of paying rent or monthly dues?

YesNo

How will rent, dues, or other fees be paid?

Are you currently employed?

YesNo

Current Monthly Income ($)

Current employer's name & address

Are you capable of working or volunteering?

YesNo

Work experience (trades, degrees, special skills, training)

Are you court ordered to be in a sober house? *

YesNo

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 been charged with arsonI have a sex crime convictionI am on ankle monitoring

If you checked any of the above, describe the circumstances of the offense(s)

Parole Officer / Probation Agent name & contact info

Number of lifetime DWIs / DUIs

Have you previously been convicted of a felony? *

YesNo

If yes, explain the offense, date, and state/county

Please list ALL allergies *

Please list ALL medications in your possession (prescription and non-prescription) *

Are you under a physician's care? *

YesNo

Doctor(s) name and phone number

Are you under the care of any of the following? *

PsychologistPsychiatristTherapistNone

If yes, their name(s) and phone number(s)

List any psychiatric diagnoses

Have you ever planned suicide? *

YesNo

Have you ever attempted suicide? *

YesNo

Medical issues an emergency response team should know about (allergies, high BP, etc.)

Reference #1 Name

Reference #1 Years Known

Reference #1 Phone Number

Reference #1 Relationship to You

Reference #1 Address

Reference #2 Name

Reference #2 Years Known

Reference #2 Phone Number

Reference #2 Relationship to You

Reference #2 Address

Do you have a photo ID available? *

YesNo

Any comments or additional information you would like to add

Applicant Signature (type your full legal name) *

Licensee Signature

Sign with your finger or mouse in the box below.