Email
Applicant Full Name?
Applicant Phone Number?
Email
Application Date?
What location are you applying for?
Who referred you? How did you hear about us? Kindly put name of person/agency and phone number. Give Credit!
Date of Birth
Age
Weight
Height
If yes, what's the name of the Housing Company. Put N/A if not applicable.
Current Address?
what location are you applying for?
If you are employed, what are your hours/shift and what city do you work in?
If you don’t intend on working or going to school, etc. explain why not and what you plan on doing with your daytime hours?
If yes, please provide details of any criminal charges or convictions you have, including the nature of the charges and any associated legal outcomes.
Do you have a probation officer, etc? If so, what is their name and phone number and extension?
Funding Source Details :
Funding Source Details :
Funding Source Details :
As of today, how much money do you have on your card, bank account, and or in cash?
What is the total of your monthly bills?
Please disclose any existing medical/mental conditions or health concerns that we should be aware of. What have you been diagnosed with, if any?
Do you have any food or drug allergies? If yes, please elaborate.
Are you currently attending Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings?
If yes, please provide a list of the medications you are taking, including their names and dosages.
Are you currently taking any medications as part of your recovery treatment? If yes, please specify which one/s.
Do you have a sponsor or are you/will you be actively seeking one? (Please specify) If this doesn’t apply, write N/A
How long have you been in recovery? Please provide details about your recovery journey. If this doesn’t apply, write N/A
Are you involved in any other support groups or programs related to recovery? Where? If this doesn’t apply, write N/A
Have you completed any rehabilitation or treatment programs? If yes, please provide details. If this doesn’t apply, write N/A
Are you coming from another group home?
Do you have a history of relapse? If yes, please provide details and specify if you have a relapse prevention plan in place.
Do you have any specific needs or requirements related to your recovery journey that you would like us to be aware of?
If yes, what do you smoke?
Preferred Move In Date?
Any important details we should be aware of, not yet addressed?
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