Application

Application Intake Form

Complete every section as accurately as you can. Required fields are marked with an asterisk.

Your information is submitted securely to our office and used only to review your application. Legacy Living Homes follows Fair Housing Act guidelines — see our HUD Guidelines page.

1.Applicant Information

If you are a social worker or case manager completing this form, enter the applicant's contact information here — not your own. Leave blank if you do not have it.

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

Sobriety Date

Addiction History (please list all substances used)

2.Case Manager

Do you have a Case Manager? *

YesNo

Case Manager Name

Case Manager Email

Case Manager Phone #

3.Treatment & Recovery History

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 *

4.Your Goals

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?

5.Emergency Contact

Emergency Contact Name *

Relationship

Phone # *

Address

6.Financial Information

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)

7.Legal Involvement

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

8.Physical & Mental Health

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.)

9.References

Please list two references who are familiar with your life and current situation.

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

Agreements

Any comments or additional information you would like to add

Applicant Signature (type your full legal name) *

Sign with your finger or mouse

Draw your signature in the box below. Optional if you typed your full legal name above.

Upon acceptance, I will be expected to enter into an agreement to abide by certain rules and standards of conduct. I acknowledge this expectation and confirm the information above is true and complete. *

Today's date is recorded automatically with your signature.

If nothing happens after pressing Submit, scroll up to check for blank required fields.

Legacy Living Homes

Building legacies, one day at a time

Safe, structured, substance-free shared housing for individuals committed to recovery.

Resources

Application Intake Form
House Rules
Resident Requirements
HUD Guidelines & Fair Housing
Recovery Resources
Success Stories

Contact

(510) 200-8957
info@legacylivinghomes.life
Service Area: Sacramento Bay Area, CA

Disclaimer: Legacy Living Homes provides sober shared housing and does not provide medical treatment, detoxification services, psychiatric services, or clinical counseling.