Application for Membership for Sober Living

1) Print Name (Last, First, Middle)        Social Security #

2) Date of Birth (Month, Day, Year)

3) Present Address (Street, City, State, and Zip Code)
List if Treatment Facility 

4) Phone where you can be reached
Home -
Work-

5) Are you an Alcoholic? Addicted to drugs? (Please circle)
(Yes/No)            Date of last drink
(Yes/No)            Date of last drug use

6) List drugs you used addictively.

 

7) When did you attend your first AA or NA meeting?

8) How many AA/NA meetings do you attend each week?

9) Do you want to stop drinking and using addictive
drugs? (Please circle)
Yes/No

10) Are you employed? (Please Circle)
Yes/No     If “yes” list your employer.

11) Are you getting welfare or other non-job related
income? (Please circle) Yes If “yes” what?

12) If you don’t have a job will you get one? (Please circle)
Yes/No If “yes” what plans do you have?

13) What is your monthly income right now?

14) What do you expect your monthly income next month?

15) Martial Status (Please circle)
Married/ Never Married Separated/ Divorced

16) Do you have a medical doctor? (Please circle)
Yes/No If “yes” list the doctor’s name and phone

17) Have you ever been to a treatment facility for Alcoholism and/or drug addiction? (Please circle)
Yes/No If “yes” list the treatment provider, phone number and primary counselor if any?

 

18) Do you take prescription drugs? (Please circle)
Yes/No If “yes” list drugs and reason the drug has been provided.

 
19) Date of move in? (Please Circle)
Immediately/Other
If “other” list the date you would want to move in, if accepted, and why the date is In the future
rather than Immediately. Dates Reason

20) Have you ever lived in a sober living environment
before? (Please circle)Yes/No If “yes” provide the name and location of the sober living environment below and answer question 21.

 
21) (Answer this question if the answer to question 20 was yes.)     

I left the sober living environment for the following reason. (Please circle) (relapse / voluntarily/ other)

(Please circle) I did/ or do not owe money to the sober living environment I left, did owe money to the
sober living environment I left, I will agree to repay
the money I owed to my former sober living
environment. (Please circle) Yes/No

22) List any criminal history

23) Are you required to register as a sexual offender? Yes\NO

24) Are you currently on probation or parole? Yes\No

24) If yes to 24 please give P0’s name and number

Emergency Telephone Numbers
(List a family doctor if you have one, + two family members or friends.

Name & Address                                                 Relationship                                                 Telephone
1.

2.

3.

 

 

 

 

 

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Application For Membership

Click Here for Application Form

Click here for our Intake form